9511-110 (RPL)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
0xr) License is in full force and effect.
r4. WW r License # Lic. Class Exp. Date
F
Z n Date Signatureof Contractor
t'o Fr`
OWNER -BUILDER DECLARATION
LL
I W 1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
I.—U) ( ) I, as owner of the property, or my employees with wages as their sole
Z compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
(4)r"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 )38P.C. for this reason---._
C 1
Date / o , I Signature of Owner yr'
N .�
rn WORKER'S COMPENSATIONIDECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
Z () I have and will maintain a certificate of consent to self -insure for workers'
WO compensation, as provided for by Section 3700 of the Labor Code, for the
IZK W LL performance of the work for which this permit is issued.
J J ( ) I have and will maintain workers' compensation insurance, as required by
]] iU Section 3700 of the Labor Code, for the performance of the work for which this
j V permit is issued. My workers' compensation insurance carrier & policy no. are:
LO L rn F Carrier Policy No.
009 (This se n"need not be completed if the permit valuation is for $100.00 or less).
r- CY ( certify that in the performance of the work for which this permit is issued,
Q I shall not employ any person in any manner so as 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 those'Orovisions.
Date: I , y Applicant r
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, int3rest 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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 d ys 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 rep entatives of this City to enter upon the
• above-mentioned property for inspection purposes.
r i
Signature (Owner/Agent) i /r Dale
ALc8
BUILDING PERMIT
PERMIT4,"_ij,
DATE Il 11 ..
VALUATION 3
LOT
TRACT
JOB SITE ADDRESS 79-30 DF=T SIR&" DR.
APN
OWNER
CONTRACTOR
0WN F R/Bi.A1.DF. R
GEORGE S`MIAfT
SAME
LA f WAN'1'A CA 92253
t.81,�!
t 61 O )M'5 -62K2
DESIGNERIENGINEER
USE OF PERMIT O iJ1..Vv fj'Op, SPA
F', x 4, ANI) SPA
6'(-W 6'HIGH WALL Tu BF RF 4 0WD AND RW.At-Fl) AF IIER t *01N` `FRIk.-N(_)N OF P()().,
FEE DESCRIPTION
FEES
CONTRACT Ah4c bLINT 13'(0) IM► LS
RSTiMA'TED COST OF CONSTRUCTION
U."O.00
PF RM1 V1' w IK -F S1 IMMARY
W AN 1`111 l`k I-'f4'R 1 f)1 -(K)0 -4*#) -'i 1 R $9:A 60
CONSTRI IN WILL: lOt-000-418-000 $144 IX)
f► E(AIANICAL khh -- Pt.xk LOO -000-421-000 %24 Ill►
1,1EC"IRIC.M, Vl+ -- P(x )L 101-OW4204M $45.uo
1'1 1 MWINt IT F h'R .. IN )(A 101-1011-4 10-000 $2"l (10
,;[!l '('t.frA1. (.XANt 1T.t1(_ON AND PLAINCHECK
$333.60
US.S PRI. -PAID FEES
$O.Ou
111#71a/.'PFHM1T FF"F PUF: NEW
$333.60
tlJl:il, t'�(iJ.i1M� t '�.ltiYill 1hVEN
RECEIPT
DATE
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 y .t
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 i
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 ! 1
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.L ,
Smoke Detectors
Temp: Use of Power
Final
Utility Notice (Perm)
t
1'
%__ 1 '1 Y %--Pr L H W V 1 1-4-Jk
Contractor Owr+Cri- �yILAG—n/ Address 753qu �SukZ
Owndr -Job Address u—
This form shall be posted on the job with the Building Inspection Card at all times i
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
Building and Safety prior to work being performed by a changed sub -contractor. Failure
comply will result in a stoppage of work and/or the voidance of building permit.
TRADE
SUB -CONTRACTOR NAME
CONTRACTOR'S
LICENSE NO:
WORKMAN COMP.
NO. ON FILE
CITY BUSINESS
LICENSE NO.
GRADE/
EXCAVATE
%�//
: ✓�
I%�j
PIPELINES
CEMENT/
FOUNDATIONS
CEMENT/WALKS
& DRIVES
ASPHALT
FRAMING
STEEL/
STRUCTURAL
MASONRY
PLUMBING
'
LATHING
DRYWALL .
PLASTERING
jLR M►+� �/�Tln i«(`�
HVAC
ELECTRICAL
=Ce:.0
ROOFING
SHEET METAL
FLOORS
GLASS/
GLAZING
INSULATION
SEWAGE DISP
PAINTING/
DECORATING
TILE
/C.�ZKwc <►Z ��J TL"n �"�
CABINETS/
INSTALLATION
-ORNAMENTAL
METAL •
FENCES/
BLOCK WALLS
LANDSCAPING
OTHERS