0012-176 (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 # • - Lia Class -. E p! Date
57412T A W31/2C,
/bate . L2". 161,4signature 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:
( ). I, as owner of the property, or my eriiployees 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 '& Prof essibnals
Code).
O 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^Piave 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 agreeahat/if I should become
subject to the workers' compensation" provisions of•iSection 3700 of the Labor
Code, .I s al forthwith comply wit those provisions,
Dale:'Applicant �% / ..iiX.
Warning: Failure tosecure 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
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 Quint.a, 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 foH80 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,repre's'entativ// s -of this City to enter upon
the above-mentioned property for lnspectio /purposes
r 'i'• ' a
Date �
,Signature (Owner/Agent.�� ''
BUILDING PERMIT"..,
PERMIT#
DATE VALUATION LOT`-
TRACT
JOB SITE
APN
ADDRESS 78-775 WAKF?YiAl CIR.0,1K«.
..
OWNER
CONT��Rgqr*AppCC�T,�ORR+/ DESIGNER I EyyNG�INaE�EpR�
�/Nryi� yq 9Ld(�i��c�gq
n'YlJMi 4R21�aAd M'f,,W1,ct>
v1y t' a�� qyq �j7
-` L;.L81•VX�r DOT A76I �r4J�A�Qt.Z�.iA4J iA`J,4l1,idV��-
78-- '75 � ti�xaiF.tr�za K:t��'I.Jr.
7 011 MUMMY' CLUD T,S' , R111Yt.F4
LAOQUINTA CA, 92253
PALM DE8EE.tr_ - CA, 97,260
4" t 1 9�� �'1•G1 :; C Lft. 1044 .
USE OF PERMIT
4 YT WALL
IN
COS I'M PORWIMMON
1, 76M
CON, :PRUCTION F3:�.3� 101 -000-418,000 %154V .
ASl, D -.TO e?i.L. 0014MRi.J4_ TON AIM P1..6"sN C: -1CI ,Cts".
$15.00
1=5 PIRDPAWMIS
U,00
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVAL
MECHANICAL APPROVALS
Set Backs
I
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 HacksA
, ,
(�--
Electric Bond
Footings
Bond Beam
_f� w ��L
_
23
Main Drain
Approval to Cover
Equipment Location
_
1
Underground Electric
Underground Plbg. Test
Final �m �2�
PLUMBING APPROVALS
Gas Piping
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
Encapsulation
Gas Piping
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)