0307-004 (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
Date ��' �i.c: Signature of Contractor tr ,,c
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). e.
() 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 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.
_1have and will maintain workers' compensation insurance, as required by
S,cirbn 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 'RTATF, C0 -10P9140 -ATI Policy No. 0464i$400
(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 permitis 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 Section 3700 of the Labor
Code, I shall forthwith comply with thole) provisions.
Date: S
I Applicant / 1..� �/ ✓ -.
" EP —,,�.. a,•
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
f the above-mentioned property for inspection purposes n
Signature (Owner/Agent) -- r"" "'t</-�L�Date'%'
PERMIT #
PERMIT
.BUILDING _ 0307••
DATE VALUATION 10hWy�JFd�J."5' LOT TRACT
' 31 �-•�
JOB SITE
ADDRESS �sYfi1 C(JIT3Aa9a�JC`�
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
ID 1JR�-j' D. r1VFJ.(V1Y.r<11U
CAUFOkNU00(yu :&, opm >sf p %%tw ea
1''G Box 17
36-1 DID AVP1, i.' 34 '
LA QT.TT3;.ITA S:A 922S3
a: CACHRUL& CSA 9221 a
jfsCj 913�4��;s C] 00355
USE OF PERMIT
Ni;,1J1,d. , lii. :! tizidc?6 :.,C-1+gni+d Yiy D•i U1 i 7 i. 1,49V JUP. �i.
AI ARMOMARFi1100 4J} WAL:k,13 ` IN ifyIACE AT Ft2f<.•: H.l.�'. a t 1?it tlt�T'.F+.� `t IGi�s,
�tZI.JTb,':l��dT' ;ZidOl.fiti;TJ�'.� ;dC3'T !ta(.;.1:I;f i]SiL` ,
' Y��ld �:1�,�i?�i:t. SiS.A • 21y„p�.{� in`7 .
- R'f.UdLl4i73wSAL.W) eG."'T o.C'L'LelISTRU ISL R'OJ'AS
20101FVIN
1 hh.'"1 CHECK FEE 101-00—A39-314,
COM`1'Fr1:JC`I`ION FY -,,F 'I C?e 4Y00,418-000 0 /.flt3
4AWHA%TICAC. P.1-- FOOL 101-000-421-000 . `£24,00 .
M'li t,.TIUCA1, FZF -1100„ 1 b1-fV0-4 a'Q.•i) it n«
P3:1'Mi3I',°iCr FEi, . ;1aOE:1. - $2 l.Ot►
,`'3T.)�3••7" I �Lf - C�'a1•,13"`.M110ltt ARD 2 iA?:1 CMCK
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Lees 1YFF. •FA.?P, k'J pal
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MYr DUE NOW
MA
JUL 0 3 1003` . ;
CITY OF'LA QUINTA„ '.• ..
FINANCE DEPT..
1
RECEIPT
DATE
BY f ]DATE
FINALED INSPECTOR '
T-1.:1:'
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
o
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
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)
COMMENTS: