0212-192 (RPL)LICENSED 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
(*rofessionals Code, and my License is in full force and effect.
License # r Lic. ClaYsss Exp. Dyat�ev S� 1n
ESQ 1C,01 C514 X"I.7C.'1 MI/t7a
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Date
$d. ,*' Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am/exempt from the Contractor's
License Law for the following reason:
( ) 1,. 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
f'
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�(�) 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:
Carrier x iMPT 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 should become
Subject to the workers' compensatiWprovisions. of Section 3700 of the Labor
Code; I sh' forthwith comply with those prow sions.
Date: 1111112- /Appllcatt -_,^~7r*w fs .le.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal -penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT. Application is hereby made to the Director of Building and Safety
for. a'permit subject to� the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application -is made & each person at a
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers; agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building;
construction, and hereby authorize representatives. of this City to enter upon'
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)R ��_ % Date #
PERMIT #
BUILDING PERMIT
dd
1'9 d
DATE VALUATION M00 LOT TRACT
JOB SITE�y
ADDRESS 4.
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
DME POW Ms
MAMOND IX)OLS AND S1r AS
49 371 V1OTAt/aMWL
17;7 0,M11 MID IA: Tk? UUMB, E
LA irr .iA, CA 92253
PAVV-DEMPaT CA 92511
(7E70)200.5888 1=L6 6 3158
USE OF PERMIT ,
POGLD SPA,, 8fiytP(AMS1 Z4`1 4 0.199.5% ktp
rl�l' 1�t, e+�C'l f i Y°n�s F"�,eA47`1 H�,Fi FI�tzPs Cti 'I41 . 2:.4 3a'.Pft4y "� 1 1:rPiC:1 t7 f lk1; NOT
a$di~l.tyzi�lz
1**OM. KH)WOk3.NFA 4'%000.00 LS
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.
3'W'I CHECK FEI 103.000.4.39-31S
CONSMUC11`f.C1N �Ulp' t X314** -4.1"00 $36150
Y+l1MILAW'f.CALHIS •., PC'ot, 101.0013.421-000 12.4,00
FILEC TRfCAL, F7? •• '00f: 101.000-420-000 5.OU
PLUDADDR3 Fral T10011 101-000-419-000
y.IjCjI�Ahe CONSUtT.CTITOW AND PLfiaT C'. -19CY,
\Still
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•$"!Wa Vii' .
� �•ER9INTE NOW
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LAN 6 �Q � :V
CITY OF LA QUlMIA
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
INSPECTO
,
- INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
Ducts
Slab Grade i
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing I
Compressor
Insulation ;
Vents
Fireplace P.L. I
Grills
Fireplace T.O. t
Fans & Controls
Party Wall Insulation I
Condensate Lines
Party Wall Firewall i
Exterior Lath
Drywall - Int. Lath i
1
i
t
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
i
Equipment Location
t
Underground Electric
Final +
Underground Plbg. Test
Gas Piping
— \
PLUMBING APPROVALS
Gas Test
Electric Final
VA
Waste Lii'es
Heater Final
Water Pipir%j
Plumbing Final
Plumbing Toff Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping ;
Gas Test i
Appliances
Final I
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles I
G.F.I.
Smoke Detectors
Temp. Use of Power
Final i
Utility Notice (Perm)
Final
COMMENTS:
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