0208-217 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
C =) ch License # Lic. Class Exp. Date
d r
W
oZ r� Date Signature of Contractor
CD O."�
J U OWNER -BUILDER DECLARATION
W WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
I) 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 & P ofessionals
Code).
�
`(•) I am exempt under Section B&P.C. for trhis r /so
O N Date Signature of Owner G
VVI
d z WORKER'S COMPENSATION DECLAK ATIO
p (r I hereby affirm under penalty of perjury one of the following declarations:
LID 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 the Labor Code, for the
O � Q performance of the work for which this permit is issued.
M Q L) ( ) I have and will maintain workers' compensation insurance, as required by
Q Q Section 3700 of the Labor Code, for the performance of the work for which this
rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
r -C)
g (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,
1,hall 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
3 subject to the workers' compensation provisions �f Section 3700 of the Labor
Code, I shall forthwith comply with those provisios.
,F Date: - Applicant
IVI
Warning: Failure to secure Workers' mpens tion coverage is unlawful and
shall subject an employer to criminal pebalties 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 fpr inspection purposes.
Signature (Owner/Agent) ,4,Al-,- `-' a Date''S
BUILDING PERMIT,, t PE`RMIO ,
217
DATE'A� VALUATIONy, Loi" - TRACT
!�"+y V
JOB SITE
ADDRESS 43-810 Q'z�z��sA �nx�M
APN
OWNER
CONTRACTOR DESIGNEREEN &NEER
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43.810 MM0AU.RIM,
LA, QUWfA CA 9225'
USE OF PERMIT
PODUSPA, AT.11.t21V,tti/f: ARRIFRS 8hT,A'1, L 83 1N pi.FnCc'r, rhY2IOT TO
P0 0L AAiDIOR 3I.P.1k 1110OO.OD W
X MMD 00171' OF coh i.ridlerloff
11MMOD
PLAN CHECK ME 101 -WO -439-318 8811+96)
C01IS"FRUCTICY1.4 FVF, 1,01-00 0-416-000 $1261.00
bAEM41,0IC.. a, FE1:. `- FOOL %01-01D -421.000 g24M
14,ECTR7S:.AI. YEZ -- POOL 101-000-420-M $45.00
PLiiPll1040 FRE -- POOL 101.000„4141Mr3 O $27.00
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F,IECEIPT
DATE
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BY
DATE FINALED
INSPECTOR
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
Root 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
Steel
POOLS - SPAS
—
Set Backs
Electric Bond
Footings
Main Drain
—c
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
,Rnal
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:
CITY OF LA QUINTA
ITUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND 10B CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
.NO EXCEPTIONS!
BENCH
JOB ADDRESS
CITY OF LA QUINTA SUB, -CONTRACTOR LIST
PERMIT NUMBER
OWNE
BUILDER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized & work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by aDDlicant. "On File" is not an accentahle resnonsp-
Trade /Classification
Contractor
-FF
State Contractor's License
Workers Compensation Insurance
City Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
Licens mber
x
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
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CONCRETE (C-8)
FRAMING (C-5)
STRUCT. STEEL (C-51)
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MASONRY (C-291
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PLUMBING (C-36)
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LATH, PLASTER (C-35)
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10)
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ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING (C-17)
INSULATION (C-2)
SEWAGE DISP. (C-42)
PAINTING (C-33)
CERAMIC TILE (C-54)>