0011-293 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affitgiWnder penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profess�)'onals Code, and m_ y License is in full force nd effect.
Lice, se # Lic. Class Exp. Date
D to `' (� ��' Signature of Contractor
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of perjurythat 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).
( ) 1, 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`
() 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.
XI, 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:
Carrier. 3P,M�'" 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 nbt employ any person in any manner so as to become subject to the
worlf�rs' compensation laws of Califomia, and agree that if I should become
subject to the workers' compensation prtiovisions of Section 3700 of the Labor
f4de, I shall forthwith comply with thes�Qrovisions.
\\Date: ' 11' t'o Applicant 1
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 Safetyr+)
for a permit subject -to the conditions and restrictions set forth. on . hisI"
application.
Af
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 ^ ity, and State laws relating to the building
co struction, and hereby authorize representatives of this City to enter upon
t e above-mentioned property for iins'p�ection purposes.
VSignature (Owner/Agent) y� Date
BUILDING PERMIT PERMITq
`!
DATEi JVALUATION LOT 0011.29.3 TRACT
JOB SITE Ave,
APN
,
ADDRESS '1
54.0315 ORIM"N
OWNER
CONTRACTORDESIGNER ENGINEER.
�/
�/T � }
51.3r0A1MbA BMAD
.5137EAV'ADE Mt?AS,
X�,Q nrpCha 92253
LA QLW-1A CA, 92259 22@C9
(769)564-194152 CM0 6255 -
USE OF PERMIT
iP}'001001•r-.. laRxAa�AYrR�M'1RSMAa�R..RaqMO
.
SHALL UP, l"N PLACQtA3
PTF,..afAS_TKR
tNSPECTION, POOL, 1(Qi13,P1a9EN ENC.Ll3SURE IS 140T .NR LUDED.
P001,ANDIOX SPA .112
�S�7iMU1ATFD CC?F OF CONS':ll`lFZ7CTfON
81000M
1' it' II YRF SUMMARY
PLAN irNECK FEE 1431.900-439-316 164,35
CGHSTRU t'.aCFlhi ,FEE 1010004164 000 %99,00
MEC:iF MIC.AL FEE-- POOL 1.91.009-421.000
EL-ECTRIC AL 11, Z � P0011 101-000A2.0-0004ti.Jtf
PLLiM1 RI0 ,ME P60L 101 1 q, .0on. sr,o0
MYU-`1OTAL, CO�i3�'.1TRU(MON AAD P).,1. M CITECK
$259.35
® 3RS RE^ 1 Mai
$0.00
fix,";DUENOW
DEC 112000
SIT Yr:__ L (10A .
, -
RECEIPT
DATE,(BY /f,l
DATE FINALED
INSPECTOR
/
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 Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: