0108-211 (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- -of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class IExp. Date
Dates , -y Signature of Contractor `
OWNER -BUILDER DECLARATION (°f
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)..
O I am _exempt under Section B&P.C. for this reason
Pate Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
t () 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 thisapermit 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:
Carrie_ r Policy'No., .
1'�."X' �;L7Ni�''Ei�b.A°n'I 99tad8E34;i16� -
(This;section need not be completed if the permit valuation is for $100.00. or less).
( ) .I certify thaf 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 thosTrovisions. ,r. t.
Date: T 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 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
construction, and hereby authorize representatives of this City to enter "upon
the above-mentioned propertyf reins"'pection purposes:
Signature (Owner/Agent) v Date rt
PERMIT J/
BUILDING PERMIT =
DATE ly f ff VALUATION LOT {?j�;�1 TRACT`
P ,:
"-'
rg(y�,y�pyst
%e �±4 / �`• � � Qi.:`,As69.:+tWGAd4J T':�
'
JOB SITE " '"` z
APN
ADDRESS @ �sgry ter q�7w� y j��QpQ
'^{t6pT••[«'Ul H�.A'�13/S S,'�.G/6v7.7.C4M1CL��� ••P
� .
OWNER r
.:P.., .t^4y!+p�,��
CONTRACTOR/DESIGNER/EN (NEER
. .
i��yp, �(y.y. y /
n�„� lt.�1t°q'�J.'wY-`+..d :sL.Ca'R.rt:+A.N.I�.i.!:l!✓.SY 1�
,�q •PYpy, �•p n �edT7 cy Yy Lyn r T r�Y N?!
�F'A1.e31'�Yd`uL`dRd`L..�WI.➢.tafJ '� �.P.'i117 �1.�� yid��a9 kn���'
1''C7 .BOA. '1716
741' 25 JOW DRM, SUITE 0A
CIA 012253
PAMkBERT CF 02260
(760Y340-9000 c-Rus'l..35's
USE OF PERMIT
P001.AND10P,. SPA
k'CYSi14'P.�P"BBQ t:,Nsf 5 a'ZI I99S d F7IWIT 96 �'sCR�' L
ALM. SHALL RE sN PLAC8,A`I,` PRP;-PLAIStFf3 DIOPWT[ON,
31'OCI%..'NOT 114C.LULIFT) W PERMIT
IVOL AN13,Br) SPA. LS
EMMA (:1C1S.M 01 CONS I7:i.1'A'P�t,01N1
3010WIM
C�y�d1Y�.E�'71,+aa'.�rr:.tpp;;ryry'i,,3y�t�`i;Ax�:�t;
'
a r.+����.qqrr ��yy)) ygii vvAA
P14AYI WA'.i Y�\.�A1�n 2'A:�S+ 2 � P *L74'4��^To7�”' � n � 91 "P.93
.
C+CN.y'f'RifC T1490 FE, 101--000-418-000
MECHANICAL FEE — POUL 101-000-421-0-00 $2-440
lULECrR, 'AJ,i ET! -n P00t, . AW'h etfVit 4b�^Lf y'd$.Of3
F1.'I,iMO'k1.9CJ WLt:.•• POOL 1'01-1'000-4 105-000 Olt.00
Y `WG qq
a ,
TT
;n..
RECEIPT
DATE
BY
DATE FINALED
INSPECT
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
r
Exterior Lath
Drywall - Int. Lath
Final
Final
_
A�—
1
POOLS -SPAS,
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
_l
\ \\l
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection-
Gas Piping
Gas Test
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Encapsulation
_
Appliances
Final
"
COMMENTS:
Final
Utility Notice (Gas)
I ELECTRICAL APPROVALS
Temk. Power Pole
Und ground 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)