0102-183 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Sec l%K70W) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
�t `
Date Signature of Contractor r%
- ...T
6J a "`
' 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. 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
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.
'%('e) Ir 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:
Carver Policy No.
J101 MOM
(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 permi6s 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 Se6tion'3700 of the Labor
Coge;'1 shall forthwith comply with those provisions. 10,
rate: ' ." - ,-. Applicant ..air _J .,d ,
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.F.
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 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 pu[poses.
Signature (Owner/Agent)`- Date,
e./ u•• .,� V
BUILDING PERMIT PERMIT#
DATE t , VALUATION LOT 011112-11A TRACT
OWNER
74.923110VE-•-1eY- iL&HE SSM' 3k.3TM32,420
RAW DrESURIC .01%. 922AO
USE OF PERMIT
'-PWT.: AND/OR SPA
APN
CONTRACTOR/DESIGNER/
DESP-IT.t M iJON3jAt4UC9. O
41.555 MCCALANE
BF-RMt x?.:I i%1`TES C. 52201,
(760)'360-1400 CHIalt 3046
P0,07APA,AJ.-¢3Rb'.tWAe9.12IL11M,Sai3,ALL) UP, IN KAICZAT PRE -PLASTER
Itrd;lRCT'.ION, POOH IS NOT I'i1i;%6IMD, .
Pt.DOLANDKIR SPA
IZOD0.0 LID
EWMATRW COST QFCOBF13RUMMON
1210000)
PERI i'it' FIs I' r SAMMY
FLAN CHWIC. RX
CXW S'I'ti,L3CVON IMF,
1.01-000.41 &-000
�.t�� fil►
RVIX'TiafC?:i?.ME-POCT,
101-000420-000
P3a9r! OIN140 RE—
101 -000-419-000
%717.00
Alb7B-71 l:AAG`O:iM010NUMUC:i3:�CdR ARD PLAN iMCK
1ARNO PRE -PAW FM
RECEIPT I DATE
DATE FINALED
INSPECTOR
1"1111^151
INSPECTION RECORD
OPERATION I DATE I 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
0. K. to Wrap F.A.U.
Framing Compressor
.,Insulation Vents
P.L.
Grills
[Fireplace
ireplace T.O.
Fans & Controls
arty Wail Insulation —4Condensate
Lines
Wall Firewall
or Lath
'Ill - Int. Lath
Final
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
POOLS - SPAS
Final I I
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( 73 D(
Gas Piping
Gas Test
COMMENTS:
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rminh Wirinn
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)