0011-052 (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.
��. L&2 se # Lic. Class Exp. Date
i
Date Signature of Contractor �' '�' r" %' E
y' OWNER -BU ILDEE,,DCLARATION .
I hereby affirm under penalty of perjury that I am exempt.from the Contractor's
License Law. for the following reason
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 licen§ed
contractors to construct the project (Sec 7044.,+'Business &Professionals
Code). °' f
d
O I am exempt under Section B&'P.C�fo�this season,,
Date N � Signature of Owrier,,;Xr i "'` 'd•,\ ,
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 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:
Cartier 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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: ADDlicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3.706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on • his
application.
1. Each person upon whose behalfthis application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall,.indemnify
& hold. harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation:
I certify that I have read this application and State that the above information is
correct. I agree to comply with•a11•City, and State laws relating to the building
construction, and hereby authorize repre",sentatives of this City to enter upon
the above-mentioned property for inspecfto'ri'purposes.
i'7�.,y Y
Signature (Owner/Agent)r y + % Date
.�'
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BUILDING PERMIT PERMIT#
DATE VALUATION LOT Q�1�*k�{Z TRACT
JOB SITE
APN
ADDRESS
48-M AIJA liliDP.
OWNER -
CONTRACTOR/DESIGNER/EN &NEER
: (kaRE FORX
PC3Cs1,.•111
LA Otllit .- CA 92233
' • PALMDNw�.FtR1 C°A 92261,
(679)566-4014 (TBuz'".529
USE OF PERMIT
1101 !, ANDDOR SP1.
Ep9!��700��Ln,.(&A'SP.A..��0�1y+ff.4:'��t-ltie.S(.r,�LA�.72�:X+uyLY�il3,is''tl��pi6S�yRS ra7H+�is�.l�ti�..,tt$,1r;�y1?•3'?y�,'pk�.l��.q��',E.AT i6+�FUH,4T�+.�jyn'� a; ;
PLASTER ,1`i.,. .i.4Q C1. ,C'.k��. A4/S`V.E•E� OL �:'Q1G11"LY Y 7 f.: rd�C1X)W�.�J.tF is 0 I rd`�trS6?JiJED
.114 THIS PERNIFF &
P0011.4'rfSJ74+f i, SPIA 7 JOgYV, Yip 1B
1;X:r1VA,f01) COST OF +C.'ONS'TRTx't'�. ON
1718V0.00 �.
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t:ONSIC.Czi.lCTIONFEE 101-000.18-000 �TISJ.fFf7
.19WHANIC L FEE -- KOL 101.000-P'1-000 924,00
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;UCS RICA,t.�FYX' — P001, 101-000-4204At 0 S0.00
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Lr�`113 PRE-FAW FEK0.'1i
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'1.'aYtom PERMIT MC, S 'DUE NOW
W745 Y, -
RECEIPT
DATE 1f
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
.k
. 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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS,- SPAS
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
/L Q a
SGr a
Footings
Main Drain
I
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
t
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
w
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
-
^
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring '
1 Fixtures
( Main Service
F Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
e Tempa Use of Power
Final
3 Utility Notice (Perm)