0212-161 (SPIN)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 Bus%, s.anci
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
�Jcense 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 ofJhe Labor Code, for the
performance of the work for which this permit is issued.
(• )• I have and will maintain workers' compensation` insurance, as. required.by
SOtion `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 provisions.
Date: Applicant
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 t
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 iFis City to enter upon
the above -mentioned property for inspectio,.nn purposes.
I Signature (Owner/Agent) '�� !Date x �/ , V"
BUILDING PERMIT PERMIT#
DATE .,• VALUATION LOT TRACT
JOB SITE
ADDRESS 49-4W N"H<)W.InJ 1) VV" .:
APN
«
OWNER
CONTRACTOR/DESIGNER/EN INEER
KOL PROPP.�RATFS
A TO 2 T)AX( Y 7 K
LAQVINTA CA. 92233
1 ALU SPRw s �"_264
(760)327-1111 CD1..
USE OFPERMIT
dVil�'eM•M� it.�� 4i
SPEx At, INS�i+x" 11ON-TEMPOR ARY TPENTi, t:f7sNFRAJOR HF..nTPW &
IllGflTl', O PER TUP #2002-M
VALUATION
SPYXIA L I23SPWT1014 01.000423-6* - V00.00
3
RUD-TOThL CAND PT.JW Ir .:
$1 Mob
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1# 1�'R1;�313F:l+TCi,'
$103,t0
C1'f'f ANCE ®Ep
ECEIPT
/ATE
fj `+
BY
DATE FINALED
INSPECTOR
,r •� � J`1
p.NSPECTION RECORD
OPERATION
I DATE..• , j
..INSPECTOR.,*
OPERATION _
DATE
INSPECTOR
BUILDING APPROVALS '.
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum 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 8,Cdotrols
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
,.
Final
12. • -a2.
POOLS r..SPAS
BLOCKWALL APPROVALS -
Steel
Set Backs
- -'
Electric Bond --
Footings
Main Drain
5nnd 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
ShTp2r 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)