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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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
1
12100S
ate Signature of Contract
I.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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.
1 (4 1 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 isli's��U�td?My,�'wotk6e.,�',,.'bompensation insurance carrier & policy no. are:
Carrier Policy No.
(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 manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
s�ubject to the workers' compensation, provisions of Section 3700 of the Labor
Code, I t shall forthwith comply with,.tt;;se provisions.
Date: 112;/ Ot Applica nt,40-14'f -
Warning: Failure to s cure 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
the above-mentioned property fbr inspection purposes.
Signature (Owner/Agen Date
BUILDING PERMIT
DATE VALUATION % 1.5 - LOT
_,jX1,01I
JOB SITE
ADDRESS 79-3 15 1) USE KF W I[Ni 0
OWNER
1) E N1 A
IN -31 5 M SEICr WIND
f.A (,A IINFA 'A kJ22'%-A
USE OF PERMIT
14 )f 11, ANI 11 )k ,,;i'A
I's �01. KNI) SPA i )NI,Y
f",)L ANO)OK NVt�
PERMIT # CONTRCL#
9611111-064 TRACT 4229
APN
CONTRACTOR / DESIGNER / ENGINEER
VA LIX Y NXN , 4t, SPA
4 741 E. PALM (.'j�N YON DPL //I I ov
PALM SPRINGS CA 0.1264
ioll,)MR-10111 C11111 21,01
0_10-01mv I -Is
Li'STI'MN11.0 COSTOPCONSTRO('130N
PERMIT VEF SIRNINIARV
KAN 04HECK M-1 10 1 -OW-430- 318 $99.45
C'(.)N6f1ZUC_7i'I0N FEE 101 -ON-M-ow S 153 W
MUCHANWAL 1,10i KX31. 101-000-.121-000 U"ov
Ff-H - W-K)II. 101-11)(91-4210-M) $45 1XI
PLUNI'BING IFFE -- ixnoi, 101 -MO -410-000 S270)
— 'A
SUB TUOU, COW;IIIUCTION AND PLAN CHECK
LESS FE.R.'s,
TOTAL NMIN1111T ITT.4 DUF NOW
1113.."111.00
$3,19 45
$000
S.1418.4.5 -,
RECEIPT DATV ,n BY' (L I ,/ INSPECTOR
��l /; I DATE FINALED I I
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 L.
Grills
_En! il
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS-,/
Steel
SetBacks
Electric Bond
Footings
Main Drain A
Bond Beam
Approval to Co�er 4 1 N
Equipment Location
Underground Electric Ut v I
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final �z
Waste Lines
Heater Final
.-Water Piping.
Plumbing Final
Plumbing Top Qut
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
Litility Notice (Perm)
COMMENTS: