0010-050 (RPL)1LICENSED CONTRACTOR DECLARATION
C/)I hereby affirm under penalty of perjury that I am licensed under provisions of
I— C;" apter 9 (commencing with Section 7000) of Division 3 of the Business and
c*4 W P; ofessionals Code, and my License is in full force and effect.
CD :D th License # Lic, Class Exp. Date
r�dLOLU —N J )
oZ I,- Date +u f -Signature of Contractor
O�
U CD OWNER -BUILDER DECLARATION
LIJ W Irl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
rn
2<
WORKER'S COMPENSATION DECLARATION
o I hereby affirm under penalty of perjury one of the following declarations:
Lo F- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U (v) I have and will maintain workers' compensation insurance, as required by
O U QSection 3700 of the Labor Code, for the performance of the work for which this
Mpermit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
06 5
C)
Q (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:
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.
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 purposes.
Signature (Owner/Agent) 'r. �" Date {' f
BUILDING PERMIT PERMIT#
DATE I VALUATION LOT 1-ZO _ .-. TRACT
JOB SITE APN
ADDRESS
al- -IF-, OW01i WAY -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CAROL BIINHM
OTRR d , DODSON COWDRUCTKi,N
7q-'753.1 (RION WAY
VN 13 COUNTRY GLUD D& IM! 17,17F4
x.A.tl T ifti i::+ 92M
PAL• A i)FI .Rql CA 92260
(760)346-4032 CB1R M111
USE OF PERMIT
I l+.WDPE _k VA
I'W1,&;PA csi IX -ALARM MAIZ1<aZRS SiilsU JIM IN I►! kCr AT F'RK
111-AS'I ER 114SPECTIOla,i'001, EQUI'PWNT 13 W0T 1W4, U1)F1')
n4 TWIS lyXi.MIT
1100L.AWIVOR JPA Its,m).w I.I
MnMAT". 1170W, OF COAM NII(.MON
PLK?I C11= FLS ! v! -i3WJ -3 l9• � I L� $t �8,7�i
VEX 101-N)O-418-00.7
WC HA>"1 AL FEE, P1,101, 101 -000-4 21 .000
LSI U:(_'3`PJC*AL, YXV -„ P(A.)L I OI -MO-1 d5, 1141
PLI?AIl1140rt YEA .. P( 6L 101 41tD A Z 9-I)m
STA•7OITAL.x><113
.�.i•Y 'i 3:-1_.l..F.9,1p-..A fl•:i..'
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERA" JDATE INSPECTOR OPERATION DATE ` INSPECTOR
11. nMECHANICAL APPROVALS
Set Ba Backs
I^ Underground Ducts
Fetors & EL-111-1,—
Siat+ Grade
Roof Deck
O.K. to'; J1 la
rraminn
Insulation
Fh'up.�e P.L.
Flrepiar:r T.O – —
Pr��y 4Vr 1i insulation
rpa:ly WaA Firewall
rz�.tklr Lath
C]nvsrail - Int. Lath
BLOCKWALL :APPRO'JALS
Set Backs rt — — _ I I•_
Bond Beam – –
l — - PI..UMB� NG APPROVALS –
�
Plumbing Top Out
Sewer I.A, .m[
Piping I _
Test �I
Final I I
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole j
I Underground Conduit I
j Rough Wiring
Low voltage Wiring l
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. -F-1.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice
Ducts
Return Air
Combustion Air —
Exhaust Fans
F.A U. ! _
Compressor
vents f _'
Grills T _
Fans & Controls �� f
Condensate Lines
I I
i
Ele;;iric uonci
J Main grain
Approval to Cover
Equipment Location
1 ndzrgroui.d Electric
_ T Underground Plbg_Test
I Gas Piping
Gas Test
Electric Final
Healer Final
Plumbing Fin,.
Equipment Encicsure
j G K. for Flnish Plaster
Pool Cover
Encapsulation
Final <
COMMENTS:
*W
�7
t l ( Clz
11q10(
tl l,71-oP
OVFW-