0106-068 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professio als Code, and my License is in full force -an ..effect.
Licen. e Lia Claos Exp. Date
C33 4111"1 11.13W6T
Date ' ,� Signature of Contractor
R -BUILDER DEC
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).
( ) 1, 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:
O 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:
Carrier Policy No.:
3'I'ATE, FUND A 1a9UNi;f-
(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 anAmanner so as to become subject to the
workers' compensation laws of Califo�r'''a;and agree'that if I should become
subject to th�es workers' compensatlq-p rovisions of Section 3700 of the Labor
Code;il sh fl fo h ith comply with those irovI ions.
Date: f Applicant 's .
Warniii6:` it e to secure Workers' Compensation coverage is unlawful and
shall subjecYan, . mployer to criminal penplties 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, interestand 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 ifs
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 thbuilding
construction; and hereby auhorize representatives of this City to a ter upon
the above-mentioned property for 'nspe tion purposes. t'
,r'
Signature (Owner/Agent)'�� Date
'BUILDING PERMIT PFRMT#
DATE / VALUATION " LOT TRACT
JOB SITE APN
ADDRESS a
. 46^�i 4 '9�e'
MARALOMMO -
OWNER
CONTRACTOR/DESIGNER/EN INFER _
I"gi&WISCAI"Do
CONS=
YAW. 2ha
440.64, YWAAAL01060
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LA QUWrA CA, 9.725:5
LA Qj:TWrA CA 92233 .
(760)564-3655 CS3up
USE PERMIT
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EIMMATSD COST OF C011191MYCnON
"100010
PJAN CH.E.M. KIM- 1, 01.000.439 318 �1b'1.t30
� F1:r9`ILiIC'E`I.Gxa�tirLi. 101»000.419-000 $252.00
MECII'IANHOAEr YU ' P 0bo 101-000.421.000 $2 .00
11AYC'`"6.'yh'l��EYY3,FiyA.-/O�Rry1Cryi-420-L9143y0 $4300
—P Pt 011 1101
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41L1E3-"'Y`VAL CO1� IT l�"J'�':� ON:+r1.t`i) PEAR' t^;F�'?1a'Ci�:
$5,11.80
' ► s l 1 y VES DUE
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RECEIPT
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DATE '` IP r' �,
alit t 4��
BY
DATE FINALED
7
INSPECTO
Ate,
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 Wall 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
�.�.
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
CC//
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 Servi
Sub Panel
Exterior R ptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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