9704-120 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury'that I am licensed under provisions of .
Chapter 9 (corr+mo_ a_ciag 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
Date `"� '� Signature of Contractor
0
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 undergpenalty of perjury one of the following declaration's:
() 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.
(N 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:
Cartier Policy No.
(This section need not be completed if the
() I certify that in the performance of tl
I shall not employ any person iri any ml
workers' compensation laws of Californi
subject to the workers' compensation pr
Code, I shall forthwith comply with -those
Date::" �_r1' f Applicant
t valuation is for $100.00 or less).
-k for which this permit is issued,
so as to become subject to the
i .agree that if I should become
is -of Section 3700 of the Labor
provisions.
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°`f'rom 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(
correct. I agree to comply with all
co struction, and hereby authoriz
t e above-mentioned property for
'Signature (Owner/Agent) .Z
state that the above information is
State laws relating to the building
itatives of this City to enter upon
purposes.
Date • rj�
BUILDING PERMIT PERMT# CONTROL#
�,7f14.14�: 5 047
DATE VALUATION �iWLOT TRACT .�
5/ f $1.404 'tit) f r3 ' 1
JOB SITE
ADDRESS ' 794055 VOA. SAN i°Il:,laRA '
OWNER
CONTRACTOR/DESIGNER/ENGINEER
P+"kt1c.t o 1„ v t')u1A"#`,4 ("'01J^f'f`I.'t' r'f'tjA
C-0,1 Oj''e.Eti IA NOOL S it,. SPAS
7-_V)53 V Iri. A_N t: LARA
i4-115 .iOIQ ORM",' rel',.
I,sl, 011)NI-A (.'A 9TM3
MAI Dhl."aERT' CA 02260
t'76tlMO.91000 C 818 4367
USE OF PERMIT
1-4X A, AND 'SPA ONj.,S'
110401. Alii)/+',k 3PA 11"000.00 I.S
r�tn?Yi.Ii�ltfi'lEW OS ('�i? CONSTRUUIC3td3
y�€iii4P,i i
PERMIT FVRS(fN01AHV
t}l AN C,fdF,C`1+.'1�'t 10.t-43t)t)-/1:39-31�; $y:..�cM-.
C'0N, `!°R ("!`))N'l.r; . 31)'!.#1(ilt. 1}�P( )f) tt5:3.f*
X -MR- kif'UN[Q-.Xt 479 -_'. P00L 1.01-000-12.1-000 $24.00
LOW`t'IRICAL• MAE ._ KKK)L . $45.00
o`
!t>1 tlibfiilttilCdF1?-;iyOc�l, !C)1-U0t)-�fi'+-t1tN} $27'.00Cn
•
p o,
e
`r Jt3-t't`J`FAL CnMPrfit..fMION,AND PLAN CK Xl'l�
LS !.'.R1s.'f'f1I19 F BE
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
rms & Footings
Ducts
ab Grade
Return Air
teel
Combustion Air
P --)of 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
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 Q
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:
Q