0006-112 (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 J Exp. Date
574:27 A08,43,J/112(
Date e� tr Signature of ContractorA«-�`-
' l
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 bf 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 STATEFU14D Policy.No. 046-OD-00OW34
(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 per'so'n 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
Code, I shall forthwith comply with those provisions.
Date: /�`? 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
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,fdr Inspection purposes.
Signature (Owner/Agent )•=fir ` ti Date
!d BUILDING PERMIT' PERMIT#„11
t
DATE VALUATION LOT. TRACT
3:37450.00
JOB SITE APN
ADDRESS so -74o Tiipp1 irAo
OWNER CONTRACTOR / DESIGNER / EN (NEER
SST MjvffTAC1:`E LM MWE Y.3ODSON COATIMUC11023 WC.
7161 MTAWA '7301 I COUNTRY CLIVADR., MME Y4
RWVEP101 T�?F, CA 92508 PALM DESERT CA 42260
(760)346.4032 0134 1044
USE OF PERMIT
SPOOL AMYOR SPA
TOOL & SP,A..ONL f° - ALARMSIBA Z IERS StI?.l.t, BE TN PLACE AT
PRE -PLASTER INSPECTION. BLOCK WALL. FOR RQUIt`I.vi NT KNCLOSUIRK
IS NO YNCLLJL ZD VN THIS PERMIT. a
VALUATIO14
371450.00 LS
ESMIAM) COS' OF CON9MUCTION
:37,450.00.
P1Y W'�N'1�s'.I�': StW'1VlI RY
PW4 CHECK FEE
101-000.439«318
CONSTRUCTI014ISLE
101-000.418-000
$336.50
MZCRA141C..AL M --POOL
I01.0100.421-000
$24.00
ELN.. TRICALFEE%,POOL
10,1-00"20_000
$45.00
PLUMBING FEE -- POOL
101.000-419.000
$27,00
Stii3-1'01:AL CC3NM*12U(`°,1 •CON .A14O PLA.P1 CIW—C:K
;1!W PRE -PAM) TEES
RECEIPT I DATE
'1' Y AL FkRWd" FEE 81?1Trs NOW
DATE FINALED I INSPECTOR
$651.23
$0,00
$51.213
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
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
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
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)