0303-321 (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 # p+l �p Lic.. Class Exp. Date a j
656128 C53 .G lce ,3., J:d I. % -•
Date' 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:
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 ST.F1.T' G0MP 9.4,T1 Policy No i tir . v;l, "
(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
Bate: r.: r Applicant—
Warning:
pplicant 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 Directorbf 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 property f , r inspection purposes – -
i< ti
Signature (Owner/Agent)_.-Date
`�,V%DING PERMIT PERMIT#
DATE ` .. VALUATION LOT 4X,403_ 1'A- TRACT
i
JOB SITE q
ADDRESS �Xi..c•DrAl.t ..A
APN
- ~y
OWNER _ -
CONTRACTOR/DESIGNER/EN (NEER
IMAL . DR01MVIR, 8 THC;
fr?un--0- iwI.A:'.Ims Croy) -M.11 0.0
73129 F. WAM0 #106
80-,100 AVENW-9 54
PALM EMMTT CA —07.260
COAfif.:'KE a FAa C.A. 92213
(760)'.498.9222 ti L'tti 001-M
USE OF PERMIT
r.001, 13'P.N F$13Q (,A_'�1S 17:?,1.38.1995), 5 LA4EQU-I:P10914T VA11,
CITY 8`9'ANDA RD. .A{.,A.1M10AP.RJERS SHALL 8E TH 11LACIR.AT
P1:&MA51 ER, 3NSM1108Yd.
POO'l ANLIOR SPA 20,000-00 L
�:+1:1�: KA'�'�?:1<D C091'+"JF �' ONS1RUC".!".ION
II►► i�g���p+pY^� G�,� pry rp �,9'
117LLS.AY.f#•,.1..4+AG.R`n 9CMJ.Y3.iv,Ait, A!
18 1341, g
PLAN CHEC'M FU 101-00 0-09-318
c:t.7NISTRUCTION 111A. 101-000-4118.00{1 Zcr� 00
MECHANICAL SEE -- POOL 101.000-421.000 $74.001
FLS'CTIOC°At- ISE .. 3'CtOL, . 101-000.420-000 - $45.09
1'k,Ul+ir;UNG RE -• FOOL, 'r,QO
ArPR 21 1003
CITY OF LA QUINTA
FINANCE DEPT.
UF3-`igT. COQ 1tI4C1 LC?lei,naiAPW' �X`
•Lw; A4AtL.P11.9MTF •yEG.S i¢L7E X06
OA35
RECEIPT -
DATE,, _
BY
D T FINAL ,. IN CTOR
/_
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
POOLS - SPAS
Steel 41_
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
l ante 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
Gas Piping
Gas Test
— — – – —
Appliances
Final
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)
COMMENTS: