9612-114 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalt-y"bf pg%,,,y that I am licensed under provisions of
1-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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C\I LU Professionals Code, and my License is in full force and Aect.
C—) D co License # Lic. Class Exp. Date
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z r� /bate nature of Contractor
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F– OWNER -BUILDER DECLARATION
u
W UJ (0 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
[L
U) License Law for the following reason:
z ( ) 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 am exempt under Section —, B&P.C. for this reason
LO
C\J Date Signature of Owner
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< 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.
,K 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.
'Tre 15–M6 I
E 3 F"ONID 11,16-9
(This section need not be completed if the permit valuation.is for $100.00.or less).
( ) I certify that in the performance of thSrork for which this permit is. issued,
I shall not employ any person in any manner so as to 1pecome subject to the
workers' compensation laws of California�`and agree that if I should become
. �' fe . .
subject to the workers' compensation provis ions,.of Section 3700 of th6 Labor
.1 /;"! f . I., . . . .1.
gode, I shall forthwith comply with those provisions.
vtate: f 12-2 - V 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. ' 11
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,.ditj and State laws relating to the building
construction, and hereby authoriie , ;ri�presentative§ of this City to enter upon
the aKove-mentioned property for Apection purposes.
V9/ignature (Owner/Agent) ./// / Date
_ _ e _. LZ— __ — __ __ - _42
PERMIT# CONTROL#
BUILDING PERMIT 961Z-114 1 '
DATE VALUATION S1,5.000.QJ,) LOT: TRACT 4516
JOB SITE
ADDRESS
OWNER CONTRACTOR / DESIGNER / ENGINEER
pf.o�rclj.171) - '"
CALIFORM
8(�- 266 14 ERM MACI E 74-725 JONI DIUVE
LA QUINTA CA 92251 VALM DESIMT CA 92200
ft1J9)3"1'0-XP6 C13L-0 355
USE OF PERMIT
P CXJ L
1100T. AND !qPA ONLY
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15,00),60'11S
I-11STMIXI;V1111) COINIT OF CONIST
KAN CHK'K FUOY
M 1 -01 -MP -419-00"
f -1, 1 � ;"c 171t i (-�,A L - 6 V6 - - P 0 0 1,' 01-006-420-000 S415.60
KlYMBINO Fl!ff1 -- K.K-JL 10 1 _000-4 19-000 $27.01)
RECEIPT
SUB-Ilff Al, COMSTRUCTION' -AN 1) KAW (TOKS.
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DATE DATE FINALED
JINSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steil
Combustion Air
Roof Deck'
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
—Fireplaoe 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
—.042
114
Equipment Location
anderground P b_q_TAst--'
L
Fina
Gas ping
PLUMBING APPROVALS
Gas Test
Electric Final
izw
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
1_7-3z—'W led LL
Final
UU14 Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixturei,
Main SerAoe
Sub Panels
Exterior Rebeptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
70.
COMMENIS.