0102-071 (RPL)LICENiED-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. I =,. •. ;.,; ..
License # - Lic. Class ' F Exp.; Date
Dat a—> -q-- Signature of Contractor
OWNER BUILDER DECLARA ON r '
I hereby affirm under-'pernalty 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, Busin ess&'Professionals Code). .
.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:
( ) 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.
I -have and will maintain workers' compensation insurance, as required by
`Vecfibn 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 Policy No.
(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 shoulrf become
subject to the:workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provi ions.�
Date: I // Applicant �i 4
Warning: Failure to secure Workers' Compensation coverage is unlawfulrand
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. z
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 personDIT
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 �r inspection purposes.
Signature (Owner/Agent) r 4, , Date
,BUILDING PERMIT PERMIT#
DATE +- VALUATION LOT 6:102 P 1 TRACT
JOB SITE ` "
APN
ADDRESS t
4a,-275 TUTA QUI
OWNER
CONTRACTOR / DESIGNER./ EN (NEER
::f D 1 '"` 'E E'9"(.�V 0; wt"� ".�1T
z�+.T.�E�'f� l.it P0(31 .°3 <5? rAS
74-7 25 JONT DFIVE, HA
X.A. C)IA T 9225,3
RA; :t:+;ir�r'.�.'.� CA 922.60
C160)340-90IO (SUP 5'386
USE OF PERMIT .'
1110 W, AkTDIOR VA
PCID .. 3 Sa t11..Y.,��.,x E:B `JEl� i RLY%�.i SRA.t. L U, tg Y%.,AF"h:;.AT PRZ
IN THIS PER.M..Yr
POOL;'tN,WOR, SPA 2400,00 1.8
. "IDM.IED NFiiir 01 i. I0YqK1.R T.r1QrT
Y�.'4!YVV`Y.00
t; ON'S` RIOC .KINE i7G 101-000-418-000 SAU1 i.00
101.0.01-x•21=0t 0 SM. 00
9LbXTRKJ'4L MM- POOL 101-000-420-000
Pf.?NDMO Fes.,. Y'C'+OL 101-000.419.000
6f ..
r `
FEB 0'9 2 An
:.tU7c3-1VI'AL C:C?Ns: IDRAJMOK AN,PLA.1.dT yRX"'Ic
1103 M FATT) TOW
$0.00
I" Al"*0TAX, PERMIXF.RFS DUN NOW
1.60
r
RECEIPT
DATE , j" l
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
Waste Lines
Electric Final
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
jG}- .a -
`Y,
Gas Piping
Gas Test
Appliances
-
Final
Of
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)