0101-303 (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.
License # Lic. Class Exp. Date
r
C:g3 ff
Q to Signature of Contractor
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
Se41on 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insuratrce carrier & policy no. are:
Carrier Policy No.
U3 i 14D.
(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
sub1ect to the workers'. compensation provisions of Section3700 of the' Labor .
Code, I. shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject ani employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth , on- his pe
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a ,result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
tWar bove-mentioned property for inspection purposes.
VSignature (Owner/Agent) Date_
BUILDING PERMIT PERMIT#,
DATE VALUATION LOT 0.tf01 :jol-4 TRACT
JOB SITE
APN ,
ADDRESS
48-724 V rA PPALF'WN0
_ --
OWNER
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;ice$ 1 � 2 �3 3
PAIM �YMEW *va0. 92260
(760).340-9000 MIA M6
USE
P��ERRMIT��1�
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ydf�ii�yipr�J�21t3o31p15}7�y2eby'i�I{�gf✓�!'yaps?�Agt��p�.ilfdl.`ry.Yig%.7P:gr'�2stpgglp��2R::,. y
!�%�-6J�LL! BE W PLACE, ACE MAY PRE'PIA-0-1 FA INSI'g'7:rC B,ION,�'OO[I .G.(2UIX'.Mii,l4 i
99MG ,a,3;;t.Tltk' ISNOT Ml:l,,'idMWN T'"IS P'SR1+AM.
EMM ATM COST OF '1aO RMUC.+.il Jl'W0,AY
ds.�y�n17p,ICYFi/
Ff I, , -101.000.439.318 3tS.7.95
0014 'd 1 iC°PION FEE 101-000-418-000 $743.00
E ,,.. P00 ' ' .. ''10 1,.t -121-0
F11EC RICA1. POOL ' 101-000.420-000 $43.01)
:.
0
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TOTAL
3120,61 Amm.m.8.0m now
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RECEIPT
DATE ~BYy++"'"'.:• i
7, r 1
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum•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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS,
BLOCKWALL APPROVALS
steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Set Backs
Footings
Bond Beam
Underground Electric
Underground Pibg. Test
_
Final
Gas Piping
Gas Test
_
- --
PLUMBING APPROVALS
Electric Final
_
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster '
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
_
l
Gas Test
Appliances
Final
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)