9607-105 (RPL)a
LICENSED CONTRACTOR DECLARATION
U) 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
CV W Professionals Code, and my License is in full force and effect.'
O M License #. Lic. Class Ex Date
d rn 01ffi4'3 iia j/ I W a i/,qtr
T IJ
� W � .r
ZO N Date r Signature of Contractor,
U °) OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ D- License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section B&P.C. for this reason
LO
N Date . Signature of Owner
QC\1
Q WORKER'S COMPENSATION DECLARATION
CL
NJ- z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () �Khave and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for.the
O J Q performance of the work for which this permit is issued.
C0 Q U ( ) I have and will maintain workers' compensation insurance, as required by
O Q Section 3,79%of ••thIIe LAa pr Code, for the performance of thp,yprror Ihich this
4? LTi k iJ3Y 1 i 0- ci1:J 1.
d LO t— permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
ob
Q (This section need not be completed if the permit valuation is for $1.00.00 or less):
J () I certify that in the performance of thework for which thisfpermit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Calif orniWandlagreb that if,(R should become
subject to the workers' compensation provislor)s'of)'Sectiont3700 of t e Labor
3 Code, I shad forthwith comply with those/ provisions!
Date: A ''I r � Applicant ✓vr��Br lit it . 17
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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 appli ation and state that the above information is
• correct. I agree to comply with all/City, andJStatb laws relating to the building
construction, and hereby authorize r presentatives of this .City to enter upon
the above-mentioned property for inst e..c,/t�iof ti purposes.
Signature (Owner/Agent)' F AZA'' — Date r(,
PERMTM °°NTR°`#
BUILDING PERMIT3783 y�'�7_,"'� 3 7 8 3
r�)
DATE VALUATION LOT LOT TRACT
)
JOB SITE 794V66 NIA SA i.I,,i4llA
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'C'Al. f110 Ovit.'OJ1:. ; pjkSl
PLO, 803%, kl lf)
0 BOA.Zi I..JWALk M2
LA. QLlINTA I .A. tl2'«'_53
VALAtt M.SFIRT CA 92260
tile)?71-19A1
(4+19).340-90(X) CR1»1 -155
USE OF PERMIT
I?(;31JI_AE'il�01( 4>'1'A.
I''CKX AND SPA ONLY
9STIMATED COST OF 0ONSR17M IGN
34,iitla.ata
PL"I CHECK rflrt 1f)t-0{)0-Qin- stf� S`�.45
ONS7.'t ucrifiN FEE 101-000 418-000 5153,00
1viWWWICA"L M-1 .. Pool. 101-000421-000 $?o1.ti0
CID
ELT MC'AL'FEE -- F' Y31, 101-000-420-000 *A5.00
O cry
6'1.i,tM31NCs RE •-- P0014 101 -OW -4191,_000 $27.00
a C -D
ccSUO-Taf
Al, CONSTRUCTION AND .PLAN CHECK
$3=8.45
LEAS PRE-PA7DRE S
$0.01
'1'0'I'Al,11EMMIT I+'EEN I)ITE'NOW
fr
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
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
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
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)