0106-411 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
fn`')CAA.i451' '- �oif.�^,.6;'FI.0..' �! .�• S tiI�B.T Lf.tYd;.
Date Signature of,Contractor • :wf._
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. 704_ ,'Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to�onstruct, the project (Sec. 7044, Business,& Professionals
Code).
( ) I am exempt7under Section , B&P.C. for this reason` -
Date r Signature of Owner - -
WORKER'S COMPENSATION DECLARATION
I hereby affirm.�u der penalty of perjury one of the following "declarations:
O I have'and wilt maintain°a.certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labof 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 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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provi ions. .
Date: �„ Applicant—
Warning:
pplicant��••��
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of -compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. x
1.. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the_City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of: i$suance of such
permit,,or cessation of work for 180 days will subject pdrmit'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 four inspection purposes.
Signature (Owner/Agent) ��'-•? 1i�.r, Date %.v3:✓a9i`
J'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
s�"1�9J2tbfr �JY1
JOB SITE
ADDRESS
"7 VIM
APN
• -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r
TV 1 s1�'�:d;1"t.:i :l FVh ,O;PMf.;N '..
ORNLK P0012 OPAS (TOP MAN %01
LA CIA .92253
92260
(760)340e9000 M h. a55
USE OF PERMIT
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o a fY`4 S t. 2(✓< i+' CIP�F'+�_ W �l/�LL-CI•i'�i' S A?9F:tl� D
GAS U -0i, KA 1"MUP APPRflVZ'O APPL AUM?,
t
POOL MW' Oil VA L3
PIAN evHROK LFI 1011=000439_3 18 $1fia1,0"J
OO .SZ'RUCTtOP'd1;'.@ , 101.000.438-0000
7111U�d'k�ING PER, ' •..
fffr.,OLOWMAL. F1Uw uA 1P001/ 101.000421-000 $241.0.0
1P,1AC"MCAL FEY — FOOL 2 0 -000- .xMOO $0,00
P1,xl1i$M140 FEE am P(.'JD u 101_0w0 419:_000 $87,00
• � , I� t
- y
2001
_ 1
10:x' ., t 1 .0
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HTM.`r:C�i°/J' 9
RECEIPT
DA 'h s
L`7 J' trt�
BY
DATE FINALED
INSPECTOR
al."
INSPECTION RECORD
OPERATIONf
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
Set Backs
steel
Electric Bond
Footings �/
Main Drain
�/3
Bond Beam !! G
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
Gas Piping
Gas Test
Appliances
�a.
Final
/d /�_,Q__Z
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)