9605-016 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7721005 r
Date 4 Signature of Contract o j
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for, the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no: are:
Carrier Policy No.
(Thies;section need not be completed if the permit valuation is for $100.00 or less).
(y) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner sojas to become subject to the
workers' compensation laws of California, and agree,that if I should become
subject to the workers' compensation'provisions of Section 3700 of the Labor
Code, I shall forthwith comply with -t ose provisions./'
Date: Applicant__
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a• permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant'to
any permit issued as a result of this applicaton agrees to; & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City,,and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
t1
%1e above mentioned property fo vinspection ptl poses.
Signature (Owner/Agent)'`°' _D,ated—/.y,4 C .
BUILDING PERMIT PERMITuCONTROL#
2 7 8
V
DATE 5/ 8/96 VALUATION $14,00.00 LOT . TRACTJOB
SITE
ADDRESS 4.5-450IMS1ti:W AIM,
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JOE, J ili.t�.�.NE;fi
`�'A.1..:.E Y 1'1313[, &SP"F.
4—'-4501)ESIs1t1'A1.K1~:.
4741 C.E. P. l Ai CANYON 1A 11116
LA OUINFA CA 42253
PAIR SPRINGS CA 92:204
36k-1'766
.778-3935?
USE OF PERMIT
I�t3�C)1,,A1~�131�J:1� S1,+,q
P001, ANT..) SPA ONL`5 l3t� ims suviu.,ST Kr t ciwq)
t:'z.JUA. Ii.tN1JIVK �t"ti. kq,4+uu.� ...:�
USTMXIIIN) (.10151'r OF CIONNISTRUCf ION
14100.00
PLA34 (AWCK FFE
("Otis` 111,t1iM.Chf.V1761 $'lS3.Si9t
ib1133,C't4M11Cft L 177'aE ,- £=" )OL 10.1.(?00.421-000 5?fi.vG
GLF t1iCAL A`; "ts _„ l�c3C t. 1A1 iCN 4d[i 1(10 .+X►
l�%tlt�i€�1N�1'r`tssa;.�:W�`�3. 113R-(iC3f1-fdl��•t1tN1 ���.t�t
SM -TOTAL -t:ONS'TLi:,U'C.`7'1ONAND PLAN CHECK
$348..15
-LESS i'tkrt-PA1C3F EES
$0.00
TOTAL PE9t(1 IT il'.+I;RS 1YUK NOW .
$344.4.5
~_N
RECEIPT
DATE ..: "
4,
BY
DATE FINALED
INSPECTOR
.. •'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
'Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping t,
PLUMBING APPROVALS
Gas Test
Electric Final MID
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation '
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
l_ 1 "1 Y yr LH %.,*V 1 IV'1'H
Contractor 1t- Address �11y/cx—
Owner��, � ��,C,✓�� Job Address yJ�yJb��sc�ZaT�-%tom%
This form shall be posted on the job with the Building Inspection Card at all times is
conspicuous place. It is the responsibility of the General Contractor or the Owner/Buil
to monitor the sub -contractors that are on this list are the same persons performing
work. Any changes.of this list must be approved by the City of La Quinta Department
or
Building and Safety prito work being performed by a changed sub -contractor. Failure
comply will result in a stoppage of work and/or the voidance of building permit.
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TRADE
1i
SUB -CONTRACTOR NAME
CONTRACTOR'S
LICENSE NO.
WORKMAN COMP.
NO. ON FILE
CITY BUSINESS
LICENSE NO.
GRADE/
EXCAVATE
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FOUNDATIONS
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FRAMING
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STRUCTURAL
MASONRY
PLUMBING
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LATHING
DRYWALL
PLASTERING
HVAC
ELECTRICAL->'�yc%!�J
ROOFING
SHEET METAL
FLOORS
GLASS/
GLAZING
'INSULAT:ON
SEWAGE DISP
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DECORATING
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METAL
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BLOCK WALLS
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