9905-189 (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 # Lic. Class Exp. Date
09W45 B ),
az
Da e Signature of Contrd�tor
OWNER -BUILDER DEbLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
I arn exempt under Section B&P.C. for this reason
pate Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby. affirm 'under penalty of perjury one of the following declarations:
V�/,J-,Aave 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.
( ) .1 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:
Carder Policy No. -
row)
(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 pers on in any manner so as to become subject to the
workers' compensation laws of Calif ornia,.,and agree that if I should become
. "." .1 . , 3700 of the Labor
subject to the workers' compensation provisions of Sec iron
. . /., . . e.
Code, I shall forthwith comply with'ikose provisions
Date: Applicant—"
z / I
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 th6 LabQr 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 ;1'. Each person upon whose behalf this application is made & each person at
%�hose 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..
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
6orrecf. I agree to comply with all City, and State laws relating to the building
construction, and hereby authoriZ6'–representatiyes of this City to enter upon
the above-mentioned prorerty for ins . p , ection' purposes.
"I
�r;�gent)
Signature (Owne fi_ _!7�_Date
PERMIT #
BUILDING PERMIT
"054 89
DATE VALUATION LOT 37 TRACT
JOB SITE
ADDRESS %-74SCitkV4i)TRA'�Tl,,R.Sl�:AVFK
APN
I - .-
OWNER
CONTRACTOR I DESIGNER I ENGINEER
UVICINIHS, 11f1c
PJT INIVE911MNITS, IN"'.' 111UT
X810
PO B01
I
1425 E. UNI'VERSilT DRIVL
LA. QUINTA. CA 92253
RHOINIX AZ 85034
1 o6 CMA 4iAl
USE OF PERMIT
PCX)L ANWOR SPA
rOO1. ANVOR. SPA, .1 1,000.(k) 11
ESTMAT IM COST 0 F CONNNTIZ 'UCTION
1110111)(1111510
V ERNAI VER S UAIMARY
Pl.�AN CHUCK rEE 101-4,1004_09-3W s8i."
C0N5TRUFCT10N- RK 101-0M.418-410) $A26.0
NIIECTWAC.AL PEC __ V0011 _,Iw 14)00-v,.1 -Goo V 4. 0 0
ELAX�TRXCAL FEE, --POOL
NIUMBINO FFV_ _-_K)(yL 101-000-4,19-000 12701
ol YB-MMAI, CONSTRUMION ANU) PLAN (-HECK
$30390
LESS PRE -PARD FEES
$0.00
TOT AL PURAM11"PEES DUE'NOW
$1 mlil 1) 0
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
DATE
TINSPECTOR
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
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
12— V K
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: