0211-025 (RPL)LICENSED CONTRACTOR DECLARATION
•' I hereby affirm under penalty of perjury that I am licensed under, provisions of
I`_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N w. Professionals Code, and my License is in full force and effect.
'i 0 M License# Lic. Class Exp. Date
LO
LLJ Q'153 FIX 11V_1 3 AIM
o.Z 1Date >Z Signature of Contractor f &¢„��' 4 1Y
CD 0. f
J6 OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
U) .
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 (Seca 7044, Business & Professionals Code).
( °) 1, as 'owner of the property, am exclusively contracting with licensed
contractors to *construct the project (Sec `.7044, Business & Professionals
.Code).
ICY) O I am exempt under Section B&P.C. for this reason
Lo
N Date Signature of Owner
0,
WORKER'S COMPENSATION DECLARATION
p 'Z I hereby affirm under penalty, of .perjury one of, the following declarations:
r.•0 (") 1 have and will maintain,a certificate of consent to self -insure for workers' .
X Lij compensation, as provided for by Section 3700 of the Labor Code, for the
0.� Q pertormance of the work for which this permit is issued.
y�' I have and will maintain workers' compensation insurance, -•as required by
O U Q Section 3700 of the Labor Code, for the performance Of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
ao Carrier 4,TA E Cofff"1f4j;1 ' I Policy No.
n � O
-(This section need not.be:completed,if the.permit valuation is for ` $100.00 or less). O l 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' compensat& n provisions of Section 3700 of the Labor
3 Code, ,shall forthwith comply wit hose provisions.
Date;- d' Applicant r
Warning:; Failure to secure Workers' Compensation coverage is unlawful and
s 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
v' application.
1. Each person Upon whose behalf this applicatiomis 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. l 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 propertyrforInspectt n pur oses. -
�12. � i..
Signature .(Owner/Agent)
Date
PERMIT# i
'UILDING- PERMIT °' ,-
,,. ,axr ' (1'x.,1.1 C+; s
DATE VALUATION ' ' LOT ,.'. TRACT
�'% ice' ori "��•
• I ' ��
JOB SITE %js rte '' c
ADDRESS 73-M VIA. WNTANA r
APN ,
OWNER ( s y{•
CONTRACTOR/DESIGNER/EN &NEER
..TD. DES)IMT �a'.��'�I•}p"°(.,O14'r �, t,
CAS t3!0. -RW N.POL & n'As a i7)�r i , xw CL).'
R0•.130XI?1tea
86-1CIO AMEHTfj, 4
LA 0I.AliTIA. ch '941233
C0d.�•�pp�.�k�'TJA C"h'ts��_V21�2.36��yy��ppqq
- Ja
(�1W)398-922 { IrBJ.l.., ViY.3.?J
USE OF PERMIT
POCTLAMNOT, 0.11k
P XUL &: S1;A Otvi3c Y. A•f,.6.i' WV0.e3lt fr)LS SHAU.+ BE III PLACE P P.10A To .:
i°i::c1i�3`P f [SI'i 114 �t '. r L fiC iJI6k 4�k3! 3 .;Nt'3,49 BRiS XCsT MCJ::JDRD
00 A�i�xxDt0K SPA MOM.ft
i
Es,,r�.�%Tl� :t3 srorCrf)���t'�.i�`}�'T�mo
x7,t 'i.
nu." 1101;00D.43!PJIG
CONSTRUCTION 117,101 ,_,•':. ;S�l t)G�a;�,.��°..tii3ti �i16(i.UG
<�
�. _ '�S.�TTTt�AL FEZ -- prat $20D
�q $20D
Zi,JOCTR tcAr,; PM _-- POOLL 101-000.42."011
LUMB1 ILI' .--'4�!JC�L 101,000-41P.000 ?°�<0
i
TWIN �)LA_H ",Ab T.,',.
Of
G,
i
RECEIPT
DATE
BY+
.DATE FINALED
INSPEC
I
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
_
Z
Footings
Main Drain
_
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
2
Underground Plbg. Test
Final � -
Gas Piping
J
PLUMBING APPROVALS
Gas Test
_
G
Electric Final
Wase .ines
Heater Final
Water' Wiping
Plumbing Top Out
Plumbing Final
Equipment Enclosure
_
Shower Pans
O.K. for Finish Plaster
_
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation A—Z
Gas Piping
Gas Test
Appliances
Final
– 3�
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)