0107-241 (RPL)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perju7y 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` "' II force and effect.
t/ License # Lic. Class Exp. Date
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( I sit ll' i
Datel" « Signature of Contractor•
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 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.
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 Policy No.
• �`1':r'i'P� 1ii�>A�P���:d�"I!`I f�9fI9°�i16f�
(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 Se ti
3700 of the Labor
Code,l hall forth ith comply with those provision
Date: _ Applicant �:. r s yf
R �!
Warning: Failure to secure Workers' Compensation overage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is'
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby autk orize representatives of this City to enter upon
the above-mentioned property fyor inspi ction pu oses.
Signature (Owner/Agent) ° { ¢ r . Date
N
BUILDING_ PERMIT y PERMIT
DATE „T VALUATION LOT-" 01.07-24$, TRACT
JOB SITE s
APN
ADDRESS
IW'iJ�� i-�kA�t��A�.LI",�:9,�5'A7n
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OWNER
CONTRACTOR / DESIGNER / EN &NEER
CWrOXY CROW .L1,, COMMMM,
C,.,IAUXARVIdE1,POC>LS & AS (r0.PMAR 001
15 3$ go, °L" qn.r, mr, arz 0, i0o
74725 S01U DR1V3, 3'C f1T;, AA
SAV 1 ,AAWA DWfi CA 31.x.45
PA1_A4'.0RWCr--C:A..9{."�y2y60
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(760)340 9wo CRU
USE OF PERMIT
PIOCIL X603 Vit?.
PMUSPA.. i[Td;1RM&FOAI?R'1VAS SI.1.r1,LL 09 TN MACE A°?' PRF P1,PSTZR
MSPA':Cl'ICAR. 12 I.F.017 5 HIGH BLOCK WALL,, CIII 'F, OTANDARD,
P001,ANDIORESPA IS
5 li°iM, ir1tAM 12.00 a,
13911MAITYI) VIM Or, MMITUCITON
MAN CHECK FEE
C0143,'i°RUCTION M -F, 101--000-418-000 MIA
990HARIC L, M •- POOL 101-000-421-000 924.00
6a.ECTI CAL FEE — PWI, 141-000-4120-000 �as.oa
PL1.li AJIMi I+'I'I'7I.^• PON, 101.000.419.000
SUR-IMAf, t't:31 M.fJ4"TION AND 7'1.Ahy CH I==
:£467.2:5
LUSS PRF-FAIDMO
s _M
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
In., Iation
Vents
Fi,aplace P.L.
Grills
FiN lace T.O.
Fans & Controls
Pa. , Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
_
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
C`
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)