9703-008 (RPL)LICENSED CONTRACTOR DECLARATION
.,t hereby-,affirm'under penalty of perjury that I am licensed under, provisions of
Chapter9 (commencing with'Section'7000) of Division 3 of.the Business -and
,Pr6fess,9ioinls"Cc-e; and my License is in full force and effect
License #' qq Lic. Class ,'' Exp. Date `
r
Date'' ' Signature of Contractor r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that.l am exempt from the Contractor's ,
License Law for the following6ason:
( ) 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):. `
C.' ) I, as owner of the property, am exclusively contracting With licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code):
O 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:
O 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 �s t 7 t nt Policy No. w,k
:� i-i•��Z.c.[•ir!avl.? �. - (^r t•^Vil�it��.f�J.._.r
'(This section need not be completed if the permit valuation is for $100.00 br'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
subject to the workers' compensation' provisions of Section 3700, of the Labor
Code, I shall forthwith comply With .thos C pr6visions.' -
Date: , t' 0 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'tienefit work is performed. under or pursuant_to
any permit issued as a result of this applicaton agrees to, & shall indemnify
s& 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.
d 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
C
onstruction, and Hereby author`iie representatives of this City to enter upon
the above-mentioned property for inspection purposes. C.
( k •
Signature (Owner/Agent) _
Date
.� - PERMIT# �. ,- CONTROL# { =
:BUILDING PERMIT - ..
. 4760
_�►_�
DATE wf/*." VALUATION►�,0lta:fHi -LOT' ® } .- TRACT
JOB SITE 6�:7aS �i}I`IuT�a�� �'iiL1.
APN
ADDRESS:
OWNER,
CONTRACTOR / DESIGNER / ENGINEER ,
k a.C'i+tl
'�ai�IiCA .li�VaIA T*ALi.�iJ .i "' -• .
5445SWIN 0) r:..
� , Jai rpt lw% ilv, .
LA. QdxifiAi'.f,i`1. Cel. 92253
PALM DI.,S41VT CIA. 91.1260
011, 40 0
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USE OF PERMIT
XXX
15004 A++ WOR SPA,114
PLAN CIWJ,-K FAX 101-OW-42*311i $40.95
CONSTRUCTION F E 101 -0004! S -0(W3 f4�..0{?ttJ)
1WIhlwc,X.LL}1:101-000-421"00/S�2
IIVI tWAL i Ca -- FQOL
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mumuw_("" ("Y` !"ul -. p(Jm 401-000-419-000 $27,0
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RECEIPT
DATE.
BY',
DATE FINALE.D
INSPECTOR
bnl;�.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
SlaD 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 112 IX 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
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: