9905-073 (RPL)LICENSED CONTRACTOR DECLARATION
I fierebyaffirm,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. Dates •f . �j
x,53
Date �f�° Signature of Contractor
i .•OWNER-BUILDEWDE TION• y
I herebytaffirm` under,penalty of perjurythat I am exempt from"the Contractor's
License Law:for the following reason:
( ) .`1, as'owner.6f.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).
as owner of. the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044,- Business & Professionals
Codes'
O I am exempt;under Section B&P.C. for this reason
Date i�k,' /t l r ''Signature of. Owner
WORKER'S COMPENSATION DECLARATION
1; riereby;.affirm under,, penalty of perjury one of the foflowing.declarations:
( ) -1 haveand will maintain a certificate of consent to self -insure for workers'
<zcompensatio.n, -as provided for by Section 3700 of the Labor Code, 'for the
performance of the "work for which this, peemit is issued. "
f have and will maintain workers' compensation insurance, as required by
;;a;Secti6n•3700 of the Labor Code, for the performance of the work for which this
r.permit is issued. My'workers' compensation insurance carrier '& policy no. are:
,Carrier. �: 1- Policy"No.
.. (Thlssection'need' not be completed if the permit valuation is for $100.00 or less):
(.)..:f certify that in the performance of the work for which this permit is issued,
f!:I>shall not employ any person,in any manner,so-as to become subject to"
Rr.workets' compensation Jaws of,California, and agree that if I should become
^,'subject to the workers' compensation provi§ ions, of Section 3700 of the Labor
CodeJ 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 to4he 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 rto, the' conditions and restrictions set forth on his
application F
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 Quinti, 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 ceitifythat' I have read this application_ and state that the above information is
correct. I agree to comply with all City, -and Statfa s"relating to the building
construction,.and hereby authorize representatives of this "City to enter upon
the above-ri entioned property for inspection purposes.
Signature (Owner/Agent) `Date
BUILDING PERMIT PERMIT"
DATEVALUATION LOT TRACT "
.
JOB SITE
ADDRESS 7q-045 tip IA A OR"iA
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
rti asst t�^�^:e �r�'t[ jDA,i' ►,I*r�•
jai ,M i::� t.:a tJ R..0 AYIL'e.1V ,4•
r �4, MONO^TIA P00T. S �. $IWS
'.vr f,. J4�,tV .. .� � t.. ��egs [la.. •
>4'"ea JOWL DRIvi ii,
LAQUINTA CA '0 T2 5 ^3
PALM [YESERT. CIA - 92,12,60
(70): 40- 0 1 3i4
.
USE OF PERMIT
I L ANSPA
5, PtkO`t LII. A%.i>,RNMI aRIERS SYALL BON H` "PRI-3:1LAST01,
Pi'xOL ANDJ0R JPS
.+ a.5.rti<, Ta , i C+��it 01.11T� a �iKKIi A V Ilk, a ai tRi
�ilaisai.�ii
PLAN 04E,C"K F ~t!, t1t t7Ut?•�13a x!38. �/I: t5
� _ �, -
t``E 101AW 41,8-009 .Ct
TYMaJAIN CAL EIM a -.POM . `101-0000-421,000
1.01,030-/420-600 �4 S:1►Qi
PtXA1]3FfhC FF.17 -- POOL
LESS PRE
MOO
TOTAL PERINIff FEES DUIDNOW
a •
&2.159.35..
RECEIPT
DATE
BY
TE I _JfzB
S
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fomes & 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
BLOCKWALL APPROVALS
POOLS - SPAS
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
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: