9606-150 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affir„e under penalty of perjury that I am licensed under provisions of
Chaffer 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
574127 A
'/Date Signature of Contractor -0 ,
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 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.
(� I have and will maintain workers' compensation insurance, as required by
Section 37QO�ofrthe�L•a�or Code, for the performance of the work for which this
t � t• [V . t s: I a(P M?s.
permit is {ssue My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(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 person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
sub,1'ct to the workers' compensa�ion provisions of Section 3700 of the Labor
C6de, I shall forthwith comply with - ose provjsions
tp
F/ )ate: "7.�1.. Q Applicant. d.c...... r.
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
cons
jiffuction, and hereby authorize representatives of this City to enter upon
/th,above-mentioned property for inspection pu poses.
ature (Owner/Agent) 9f',- r yT Dater
PERMIT # CONTROL #
BUILDING PERMIT.A1� 3553
DATE . (tW 19.6 VALUATION $16 500.00- LOT TRACT
JOB SITE
47-M! VIA e�t1��#� IN
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CENTLIRY. HOMES
STENT _1DODSON CONS TOPONI
—mu
1:35 5U. 1.) �i.(i7:F 6
6Skt05 t1.1'C:li > ;Z . f Eu
SAN IARN ('A. 92408
C A't'.1• EDRA], CITY CA A,►,2.34
{a)t3Wj:3:11 •C►p0 7
(61V).124-1232 CBLH,. 1044
USE OF PERMIT
frf,XX AUUOk.,SPA
POOL AND SPA ONLY
KS I°.Ql°1Ir1TED CMFOF C:ONSTRMir'ION
ISP iO.{1!1
PERMUF WE SUMMARY
PL C`WECi�: FEE E 101-000-4
A14 9-318 1117.0.
C'ONSTKU7L."!' ON HE ..101-0W-418-000' S1�U.i10
1WHC I1A:1d1 1kt .FVr,6 -- P003, 101-000-421-000 $34.00
cfl
FL&:.t`ft IC: A . K-7 -- P0011 101.4)00420.000 $4.5.00
PIMMONO FIa? P0f, 10.1 OW1419-000 $27.00
C]
r r_=5 m '
5.1J VIMAL CO.N '1 X1'f0N •AND T°.LANT C'fai CK
$393.00
LESS MR -PAID FEES
SO.40
*0TA1,Tl±;R11' IT FEES 13iNNOW
RECEIPT
DATE•BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I
DATE
I 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 Wali Insulation
Condensate Lines
Party Wali 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.Pibg. 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 /14
Gas Piping
Gas Test
Appliances
Final G
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)