0012-037 (RPL)LICENSED CONTRACTOR DECLARATION r .
I hereby affirm under'penalty of perjury thai'I am licensed under provision's of
Chapter 9 (commencing with Section 7000) of Division 3 of. •the Business and
Professionals Code, ind my License is -in full force and.effect. ?
` License 4 Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION,'< '
1. hereby affirm•underpenalty Of.pequry that I ani..exempt from.th1. Contractor's
License Law for the following reason
( 1„aspowner of•the property„or'my employees with wages as their +sole
compensation, will do thn
e work, and the structure is'ot intended or`offered,for
sale,(Sec.•7044, Business & Professionals Code).;
(; )0 1, as owner of the property;;am exclusively contracting with licensed
contractors to construct;:the' project (Sec.}7044;Business ,& Professionals
Code). r . t
(} I am: exemdd ptund Section B&P Crfo- r- this ceras n
Date;' 't! .. ”"'Signature of.,Owner, "' \ 'i•+.
' WORKER'S COMPENSATION DECLARATION
I hereby affirm: under penalty oVperfurypone ofr•the following•declaratioris:
( ;.)• I'have and will maintain a'certificate-of consent to self-jnsbrb.for worke rs.
compensation, as provided: for'`by. Section 3700 of the Labor Code for the
,performance of the work for which thispermit is`.issued :.
(r )• I have and will•rriaintain workers'. compensation 'insurance as required'by
Section 3700 of the`Labor Code, for.the. performance 6hhe'work for -which this
permit is issued -My workers compensation insurance, carrier & policy no are:
Cartier Policy No
,3Th.YK'4�I31�iD'., . , t ,` 39woa-X3011933-4
(This section need not be completed if the permit valuation is,for $100.00 0 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 soyas to become subject to the
wo'rkers'• compensation laws of' Cahfornia;' End ;agree that if 1 should .beconie'
f :subject, to th`e workers .compensation provitions N Section `3700 of the Labor
+ Code; lttshalf ford” vith,comply with 'tthos`e provisions, 's ,
Date.. t'd r• � •. APPlicant � .....-,--•:...C�'t,3 •q .•.r j_ � .
Warning Failure to secure Workers Compensation coverage is unlawful and
shallsubject an employerto criminal penalties and'civil fines up;to $100 000; in
addition*Ao th'e`cost of compensation damages as•provided-for in Section 3706
of the'Labor Code, interest and attorney s,fees
IMPORTANT ,Application is hereby matle4to the Director of Buildingand Safety
.for a -permit , subject'`to: the 'conditions ; and restriction`s ."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 this applicator agrees to 4, sfiall, indemnify
&.hold karmless_the.City of La:Quinta,,its,officers agents and employees:
2 Any permit issued,as,a.result of -this application becomes`null and voitlif
work is not commenced within 180 days from date of;iissuance of such
permit, or cessation of work.fo"r;180 days will'subjecfpermitto cancellation:
L.., . � . . i' .
I certify'that I have read this application and state that the`above'information is
correct: 1 agree to comply.with all City; and,Sfate laws, relating to the building
/consiruction,.and hereby authorize representatives of this City to enterr upon,
the above-mentioned property forinspection purposes
Signature'.(Owner/Agent) "'~� " ,'t � Date �,K'
r
BUILDING`PERMIT- PERMITtt
DATE, VALUATION LOT.1).B>6 TRACT,
"
JOB SITE
�_,A
ADDRESS
OWNERCONTRACTyO
Rp/DESIGNER ENGINEER
AND
yIVLLAN
VQlCpkpJI
"HAL Y�Vj NA(WJ0M iOMS i
47-06.'5 dIAAN2SJM5
LA QU . A :. CA `92125:x'
wM vALT s ' ' cA
92356 ,.
4335
USE OF PERMIT ,
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POv;a.•AN1' DOR SPA' • 140000 Lo .
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RECEIPT .. -
DATE (� (�y)
BY
D E ED
INSPECTOR
v
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 Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
1100,
Underground Electric
Underground Plbg. Test
_61
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
Gas Piping
Encapsulation
�A3�_
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)