0002-398 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing With Section 700.0) of. Division 3 of the Business and
Uj Professionals Code,'and my License is in full force and effect.
CY) License # Lic. ClassExp.. Date
o O to 636128. 'C53w— a I W1% J /20i
LLJ
o
Z
Be 21- Signature of C
:ontracto
rtc
14� _ _ \J
0.
CD
r— i.— ;-�bVVNER-BLIILD RDECI_CL
AkATION-
LU LU I hereby affirm under penalty of perjury that I am exempt from the'Contractor's
U) License Law for the following reason:
Z11 as owner of the property, or -my employees with wages as their sole
compensation, will do the work, and*thig 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).
cr)O I am exempt under S;cti6n B&P.C..for this reason
LO I
NSig� Date at6re' of Owner
0 C\J
< WORKER'S COMPENSATION DECLARATION,
z
0 I hereby'affirm under penalty of perjury one of the.following declarations:
arations:
Lo <.
0 1 have and will maintain a certificate of consent to self -insure for workers'
X UJ compensation, aslproJided'fdr,by Section 3,70.0 of the Labor Code, .for,
0,_J _J
<.. performance of the Work for which this permit is issued.
103 1 have and Will maintain workers' compensation insurance, as required
< I WO m C by
O section 3760 of the Labor Code, for the performance of the work for which this
U') issued. My workers'� compensation insurance carrier & policy no. are:
0) F permit is
-,t Z Carrier Policy No.,.,-,
usp
ob 5 r 5.11 6R
-CO
STATI:
a
.... ..
(Thig section need not be completed if
_J the permit valuation is for $100,00 of less).O ,
, - �
I certify that in the'performance of the work for which this permit is issued,
I shall not employ any person in any manner sous to become subject to the
worker„compe6sation laws of'California, and agree that if I should_become
subj6ct to the workers'. com pen sation`.�provlsi6ns'of Section 3700 of the Labor
shall fort' ',
Code I sh'� forthwith with those provisions.
Kate I? llq.T;111:4� Applicand 111V 1
Warning: Failure to secure Worl<06,:Compensation coverage is unlawful and
Shall-sbbject an'employer to . .criminal pe6altie's and civil fines up to $100,000, in
addition to the cost of,com ,oensation, damages as provided for in Section 3706
of.the Labor Code, interes't and attorney's fees.
IMPORTANT Application is hdrei6y made to the Director of Building and Safety
for. a., permit subject to the conditions and restriction's 'set forth' on his
application. -
1. Each person upon whoge,behalf this application is made & each person at
whose request and for whose benefit w6rk 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 canc6liatioh.
I certify that I'have read this application and state that the above information is
• correct. (,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 abwe-mentioried pro`p*e6y for in'spectidn purpo"s
rx S �
•
6 n)�
['7atu're '10Wh I eflAR61111
- A , Hata ?•
BUILDING PERMITPERMIT#'
DATE VALUATION 7,5".11M LOT 42 TRACT IR9_1�
JOB SITE--ADOR
U5 WA CONIQ1111i i
APN
t)49
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
PO B0,11C.17 W
14-725 P.)NI DRIVE, d1k
LA QLANI-A, C.A. 92231
PALM DUSUU CA 922,60
355
'USE OF PERMIT
1001, ANWOR S, PA
P60L& SPA 0NL-Y.%ALARJ1%QR43AMUM9 SFiWL BE, PLACE AT PRE,
700L MWK)R SI t1. 1.
IESTLM.ATED C.Ogr OF CONS 11”- f"I[CIN
TRU
599A9
PLAN Qi1DCX' FEE, 101-OW4319-318 ~ $1.22.85
C,rYK9TRU(`T)NFr-F, !01-41M-419-000 $ WPM'
4,1
'"I'll"Al M123 ..F1`1 11 4) ell#le no
iR,,.6C'FR.1kAL FEE $ i5.00
1..LUMt3JN0.1'-'EU.' P001. 101-000-419-M S27.00
$407.85
LESS PREJID FE ES
T (Y.FAL PERM UF FEVSDUE"NOW
S407145
RECEIPT
DATE
BY
ED ]INSPECTOR
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 Wail 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
jail Cly_
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Gcl
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclgsure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
— �Q
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: