9708-145 (RPL)LICENSED CONTRACTOR DECLARATION
s 'U)t.. Ih'i�eby affirm under penalty of perjury that I am licensed under provisions of
F- chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
f` Q �/at
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Z r— ' 'f7eoZ12- Signature of Contractor �` � � �m
6O� i"
J U C3 OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z. ( ) 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
Ln
O N Date Signature of Owner
0)d Q WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm .under penalty of perjury one of the following declarations:
Lo �-O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of th8 Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U ( I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
IlLO 0)l— permit is issued. My workers' compensation insurance carrier & policy no. are:
I'* Z Carrier '1r-111'4iwi Policy No.
ob
J (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
3 9ode, I shall)forthwith comply with those,provisi?ns.
JDate: `"//rri3 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 benefit work is performed under or pursuant -to S
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 ifG�
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.] agree to comply with all City, and State laws relating to the buildingf
construction, and hereby authorize representatives of,this City to enter upon
the�above-mentioned property for inspection purposseg/
\/Signature (Owner/Agent)'FDate
- PERMITk CONTROL#
BUILDING PERMIT 7��:ar�4Pr
5828
/qll
DATE VALUATION LOT LOT TRACT
IL2
JOB SITE 4.4-035 i.�li�.LE 8! LO��,�.e.
APN 1 .
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
77-140 A.VE fERNriN010
P.C.. SOX .i 791
LA QUINTA CA 92251
QLIINV.A, CA 4"53
(7160)..MO-3585 CS,1.ff 1945
USE OF PERMIT
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v.ALUATI.iNT .S
inNh�.rONT
i��7adYq1A♦4GRj�
CHECK, 17K101-OW,09' {314 $,I.ftix.8u
711({1.�p�}f�11�\i��l1t.1(i}
J.Y,11,i 1'.ti?14y1 �`�d.f-'•i;, +"''^ if�n.?A, i73A.x�7110-421-,v=q
PL ;. A-141.NO FEE -- KQL .10.1-000-41,941(10 527100
I
$r
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1,90
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RECEIPT
DATE
BY/DATE
FINALED
INSPECTOR
�a
INSPECTION RECORD s
OPERATION
DATE' _
INSPECTOR
OPERATION
DATE
INSPECTOR V
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
Stedt
Set Backs
Electric Bond
Footings
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
OX 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
Furfures
Main Service
Sub Panels
., Exterior Receptacles
G.F.L.
Smoke Detectors
'.i, -Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
+
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fp'ATTEFLED 4► . Gl „SEPT (/� QUJPftTZrM STEM ' 10
601.0 QiJ a,.p:T 177 •}yP typ
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CITY OF LA QUI
- • BUILDING & SAFETY DE.PAR
CONDITIONALLY 4
ACCEPTED FOR CONSTRUCTI-
SUBJECT TO INSTALLATION AS - - - —
• I Gla.si
AND ALL APHLICABLE CODES
BY �,J5ry
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