0106-128 (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,#, tic. Class Exp. Date
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 constructi.the project (Sec. 7044; Business & Professionals
Code). j
() 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
gection 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.
rSTATE FkMD . 161426"1
(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
subject to the workers' compensation provisions of Section ;,.3700 of the Labor
Code, I shall forthwith comply with those provisions. '
Date; Applicant--_
Warrting Failure to secure Workers' Compensatlon�verage 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 a 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 cf 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 for inspection purposes.
T A'
Signature (Owner/Agent) VL _� X 4Date'6,,. t.-
BUILDING PERMIT PERM T# _
DATE VALUATION LOT .-TRACT .
JOB SITE
ADDRESS
APN y
Q10 AWKNIDA VH Ems.
w
OWNER,
CONTRACTOR / DESIGNER / EN (NEER:
!:':r lM. azo 's U10.
AO. its} RES t;,,:ONBTR'.lM-09
74-596 �� �'PEiC'iM DWIVE
81-900 MMUE 52, 00
PALM,7WERT CA V2260
INDIO t%L'9. 92201
(760)772.2848 Mft;# 1451
USE OF PERMIT
.P001,,0N1.Y.C+AMP1RM.VRA.1RR'4=.SeY[iAIA,PM.>r4 PIALCK.c` T P11F.-PLASTER
Xk SP9,C'1"ION, EQUIPle�11 ITT PING .KzSf.9.P.9. A-1 T INCi.ilDk D N' T 111s. PEPM.1't
f
X81M 3a'llM 17.09T OF COITS"MUC'Y 7C0N
P'M`rb_%'1 f: SUMMARY
PLAN t;sMIK FEE 01.000.4,9-318 $3511P
88STH.'UC:fT?O-H FVE. 101-000-418-000 $:.4.00
VILUMV'iliiO MET— -• POOL 101.000-'# 19--i a' $277.00
r
-TUrK N AitT:f9PLAN C XI
'185.10
LESS FRE-17AMFE S
1
$0.00
I FFIE6 SDI E R` w
$1110
,y=am
RECEIPT
DATE /
BY
DATE FINALED
INSPECTOR
1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
T 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
Set Backs
steel
Electric Bond
—57
Footings
s
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Jottage Wiring
les
Service
r�u6 Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
`
Final
Utility Notice (Perm)