9911-214 (RPL)M
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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
sslonals Code, and my License is in full frorce and effect.
10 S. iZS2 11,�1as"s ,� Exp.912,31/2NN
Date 12-2-M Signature of
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 ;;rATIi FUND Policy No.
05171)16-
(This
)SI '315
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) .I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any maniper so as to become subject to the
workers' compensation laws of Californ'a, an�a ree th if �,should become
subject to th pworkers, compen ailo �rll Ens of tion •700 of the Labor
Code, Yaall�orte*llr �complP5v� t0hos . i il n .
Date: Applicant
Warning: Failure to seclfrerWorkers' Compensation coverage is rnVful and
shall subject an employer to criminal penalties and civil fines up Ql00,000, 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, a uthorize r presentatives of this City to enter upon
the above-mentioned opeer, Ac S ecti ufposes.
Signature (Owner//Age t`� Date _r
L�
BUILDING PERMIT PERMITX)l1 214
DATE /%�j` VALUATION $17+f T -1H) LOT TRACT
JOB SITE 19-090 DMI11' i S1 Id 1.4.'11
APN - -
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
N!"IM111.11:1' H %R,IIING
SU"N. ",, PIWILS
79-090 D1 SER 1' STR1:AA1
P (). BOX 835
Lr1QltINI-A CA 14-7253
;PALM DESERT CA 41251
(041--W-4014 ('BI..# 524
USE OF PERMIT
P(AN, ANfYoK *sm
0,"L ANLL ZWA QNL ] -A LAMLviSAi:S WAS 311AL.1. Lig; ifv PLACU A i Vkh
PLASTER INSk'H'l ERIN
i .K4, ANWOR &FA 117.SWU3 LS
STEMATEDCi5rOr>;,'f3"rri P%VC1r10N
-
17.200.00
PERMIT FEE SUMMARY
PLAN (:RECK kY-F,' 101-M-439-318 SIZ1,bi
CONS'IRIR"t'TONF F.' 1(11-( ff-d)9;-(t(x(i S1 wrtfl
NUX-11ANK'AL F1:1 -- POOL 101-000-421-000 52100
i~`i.W(ftir.'AL I+.L -- 4'kX T. 1011.OW-420-" S45.04)
PI.UA1BINIA FEE -- PWI, 161-000-411)-WS27.11K►
SUB --MAL ('(V4q, 'P.I (-nC)N AND 11I..AN CI CK:
$407 gi
LrNs, RXI-PAID F1;ES
$0.00
TOTAL. PERMIT FEES DUE x+tO W
S407.8.5
1w A.
RECEIPT
DATE
B,Y,.i
DATE FINALED
INSPECTOR
`~ INSPECTION RECORD
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LNVERATION
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Hacks
Footings
Electric Bond
Main Drain
—
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
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
-t - "Lt —C
COMMENTS:
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)
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