0305-224 (RPL) LICENSED CONTRACTOR DECLARATION p .PERMIT# i
I hereby affirm under penalty of perjury that I am Iicen7d-under provisions of BUILDING PERMIT a -22il
I- Chapter 9 (commencing with Section 7000) of Divisi n 3 of the Business and DATE .` ,/ '�rVALUATION LOT TRACT `
(n 9 fi' 4... ' ,aF�(11
04 W Professionals Code,and my License is in full force and dffect. e ! y., ``
O M License# FF /a Lic.Class Exp.Date
d �'F� � i J3 Tric �� :�O� ADDRESS 4t-754/ VILA DRIVE JOB SITE APN
` ~ J'
Z t- y,/Date �-' `Signature of Contracttq OWNER CONTRACTOR/DESIGNER/EN INEER
O ' UR
/ ? 4. �• r 3 - 1A'iI i�f:iiF ..1 .'L� rr//.. t^. '/yyNppTT {{LD 8 AiOR ..yy..pp
Co OWNER-BUILDER DECLARATION
aI hereby affirm under penalty of perjury that I am exempt from the Contractor's LA '"I �a A �� ,y3 `d D ? �. GAI 9226
U) License Law for the following reason: �r
Z_ ( ) I, as owner of the property, or my employees with wages as their sole �'Y6 ))316.5076 CU4 :13;x.•
11
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed PPI,I'NIVOR SPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). wr„ .•aU,!r,.n.nitsrfkm I K31.11,VUk5fWX.5WjM P V,Al : E-,r L-AASs su:
U') () I am exempt under Section , B&P.C.for this reason
N Date Signature of Owner
ON
0)
L)
Q WORKER'S COMPENSATION DECLARATION
�,
IO Q Z I hereby affirm under penalty of perjury one of the following declarations: P�CIL j11;1°1D1011 SPASPA00.0 1A
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
m0 J Q performance of the work for which this permit is issued.
Q () ( ) I have and will maintain workers'compensation insurance,as required by
O (-) Section 3700 of the Labor Code, for the performance of the work for which this
a+LO I-permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier KXYM i' Poli No. RS"I'.�I+ATMI aK:)�t'„Off C€,yt�'S'MUMON .�,l�G�+,�1•
Q (This section need not be completed if es'pei valuation is for$100.00 or less). ft AN j i1JG.er,.Yrli: 101400-4 39.31£ $33.10
J O I certify that in the performanc o the wor for which this permit is issued, CevlUST UCT10,14 EE 101-000-4113-000 $54JID
I shall not employ any person in y ann r soasto become subject to the AIE1~:�::}Y�,1y;G�1,,3; „-NI;yOL 'i(;},•i)Q)(9.421-Of,,4p $24,0
workers' compensation laws of Califotnl , an�tl agree that if I should become L;1 1rY�:'1'�1AL Y�;E-POOL 1,01-000^420-0W 245.00
subject.to ttSe wort er +compensa ion rovisi'ns of Section 3700 of the Labor e 101-000-419-000 %27.00
P. ��i PL.1:-L�`�:•03 IM, POOH
Colie, lcsh Il Iforth�vicomply w� tho .pfisions.
,.D'ate: _ ) Applicant f
Warning: Failure to secure Workers'Compensation coverage is unlawful and
` shall subject an employer to crimiRalppdnalties 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 SITa-I'I AJ (,'lir•MMOMIJ.f N AND ISL LL"T 0''TR K ' 2 f 81 1 l3
whose request and for whose benefit work is performed under or pursuant to LEM PRE-PAID,TE �i0
P:t2 .00
any permit issued as a result of this applicaton agrees to, &shall, indemnify
& hold harmless the City of La Q Intq, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if /1 �1 aw'VIENIM-Cn7sDUE,Now �315�°1P
work is not commenced wig
180-dlys from date of issuance of such D
permit, or cessation of work for 180 days will subject permit to cancellation. _
I certify that I have read this appli Eation hJ; state that the above information is MAY 2 8 ��� IIIIIIIIIIIIIIIIIIIIIIIII 26
• correct. I agree to comply With aIl.Cit., a�6 State laws relating to the buildi�g
construction, and hereby atrorrz' ep(esentatives of this City t• fer upon - f IE
the above-mentioned groperw�fob�1 pNtion purposes. ' CITY Cif LA rltlllt,,TA / _ -
/.' e„rt REC IPT fMN�*'DATEw Iz ! BY —•-�� �`^ DATEFINALED. INSPECTOR , '
Signature (Owner/Agent) �` � Date r it --- - , c - '1� C�
II .
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
R
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover _ d—
Equipment Location
Underground Electric — p—
Underground Plbg.Test
Final Gas Piping
PLUMBING APPROVALS Gas Test —30.-
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 —
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
R' •gh Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)
CITY OF LA QUINTA
BUILDING &SAFETY DEPT.
APPROVED
FOR CONSTRUCTION:
DATE BY
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