0307-277 (RPL)H
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LICENSED CONTRACTOR DECLARATION
'thereby 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. Pate
Date •` IK - 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'.
O 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.
( 1 have and will maintain workers' compensation insurance, as required by
Se. 'on 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 ;T A T it t'"�rNID Policy No. 14221,,1KSltia
(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 forwhich 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 oYdn 3700 of the Labor
Code, 10aJ. g,0hwiih comply with those pyo ' `i*
Date: !' �' '�` 4Applicant �T; — -
i
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal 'per alties and civil fines up to $100,000, in
addition to the cost of compensation; damages as provided for in Section 3.706
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 rep tatives of this City'to enter upon
the above-mentioned property fc�r purposes.
,�}ignature (Owner/Agent) �� ��`�� Date
BUILDING PERMIT PERMIT
030'- 7 /
DATE�.� ` -._ VALUATION l'-16,miu m LOT TRACT
JOB"SITE 7i �x;tkl INES'h F�F!'k37�ri l
ADDRESS
APN
OWNER
CONTRACTOR /DESIGNER'EN INEER
7 8-82 ',qtr !' HAU19. ra 1XIR ,t
L/'6Qr,UNTA CIA., `�21w/_1:3
't.`JOTXUMM[}:F'A SMS 922"16
'r't;+0,}3A3G1(i412 C"F..l',13 2�5;)
USE OF PERMIT
POOL Ag.D)()r. SPA.
t . .. -.. eev l 1r ... Ys: wl .a lL..i. ri, '{ K11. -A• ti: •/^l ..C4 _
>:ti'SPEC't;°IAN, E0,IIf.F"Mt.?NT l -,O C,V)SUgR"S4O`t" IN iz�D
Ft�iil..Ahif�ff3'Rit%.Pa i�,;rC►Ir,Ud S i
Pintl;R' I►'R��i')ftV: ft���rrv'fcTki��'_`�'
X11 �f ,* t 1'.k c
P3.JylPl c`'ii��lr 1'l;Js' V )."✓\��7",f�� .� 1'w
CONSTRUCTION, FET, 101-t .00-.1161.'.-+:a 0 $i: 7 i:.1;s
Y,LSCTRiC'j#1, y2 1' .. I%Ant--,:L 101 4,t45.nt
Ia9:WAi'fiK03 M" Pool' 101 !rjo-tw:f'.uf-"" 1.4
.iCvMMRIJJ vnSil�TMa..'�Pfir•`LL�?a� :%'.C:x
.. fc,37ri.;;�
MOS) PFA -MVO I RI' i
$0.00
lTOTAL F.AM ,'RaW
23 2903
CiTy 0'.
RECEIPT
DATE,/
DATE FINALED .
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms &. Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drwrall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Condensate Lines
Final I I
BLOCKWALL APPROVALS
POOLS - SPAS
steel XIN
Set. Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Shower Pans.
Equipment Location
Sewer Lateral
Underground Electric
Sewer Connection
Underground Pibg. Test
PLUMBING APPROVALS
ElectriccFFinal
este 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 Pioina
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)
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