0012-027 (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
late/A Signature of Contractor .,^"'
OWNER -BUILDER DECLARATION r
I hereby affirm under penalty of perjury that I am exempt from the Contractor''"
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, Business &.Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, -Business & Professionals
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:
O 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.
(r I have and will maintain workers' compensation insurance, as required by
Sect on 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.
'0d` MIAMODURO.1 S. R t7Z
(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' comp sation provision§'of Section. 3700 of the Labor
C 4 Opl ort comply Vii dhose pr isions.
%IUatex!-. Appiicaiii - _
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
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'commence.d 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 tabove-mentioned pperty for inspection purposes. ; '
Signature (Owner/Agent) = `� ��+ Dath�7�
BUILDING PERMIT PERMIT#
DATE t�,' VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MCI'`i+P`rM,1°'OO1.8 &110? AS
�- 1 St�:1t1 a i71 1 �a �tl
P.O. B001' 1791
PALM D1�.��?' :111 CA 92260
TA QUYk+f'.rA CA 92253
-4585 CRU 1945
A.
USE OF PERMIT
Foal ArrDAM MA
Pi &.51AA SHALL lit IN Pi.AC.'M A PRE
PAIAM i'3 SPECT[OA POOL EQUIPMENT ENCY.OFailRK IS NOT INCLUDED
IN 10110 PERMIT
PILI, ANWOR SPA 11,,500,00
SA 1 {1 -1M 09Y0 -C M1X €Tf0H
1714M.00
PR"�&�W.CFLIP RLMN"M ",
PLAW OHEW It RIX? 101.000439.318 $122 ,15
CM4STRUC:s ONi FEE: 101-000-X313'-000 $189.00
14RCHAI NXCIA,1EF1-• PAOL 101-000.421-000 $24,00
ELF. T.WICAt. M X)OL ; O) O00-420--= $43.03
PLUMBINO FES; • Poop, 1011,bob-4,19.000 1"100
((�g�'��. �1{{{''/�.��II{tt/AA ��' �•+/p'�p{�r p�� yp�,�,} pp,�r PL�y-.�+�p5'(�
. A%W�L7^.A"�O'AAL COhf�'[:�1GCTION d' N Lr�'.y��S�r`ri.+�l.'h
�1.� o� {y
�+Ss"� 0 .{l�:
����}3�']J.���r�`P
�9
' .4.� 1169 I I S -I �e d AlE43
FE
(5.
RECEIPT
DATE
B * f I
DATE FINALED INSPECT R
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final r
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)
COMMEN/TS: