0105-111 (RPL) LICENSED CONTRACTOR DECLARATION PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING,PERMIT
H Chapter 9(commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT OI.CiA ITRACT
N W Profession-RN ode,and my License is in full force and effect.
O CY M
License# Lic.Class Exp.Date
r-- dJOB SITE� ADDRESS x APN
A:V
P_ X 38446 C44 C13 ;rf
oZ r, Date : tir Signat� ure�of Contractor A, OWNER CONTRACTOR/DESIGNER/EN INEER
r- �,, OWNER-BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's 49-506 AV 11.0,DOX 564
U) License Law for the following reason: 1A QU;NTA CA 9221514 PALM 3.a;}�RM08 C& 92263_02
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work,and the structurP"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
contractors to construct the project (Sec. 7044, Business & Professionals POOL AM/43.R&A
Code).
I am exempt under SectionB&P.C.for this reason UPL,t1�:.f.:SPA.i�NL Y.AS MR.k'srpJPRC:N'�.0 PA.A3d3
u�
N Date Signature of Owner
ON
M
Q WORKER'S COMPENSATION DECLARATION
CL
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
U.) F2 O O 1 have and will maintain a certificate of consent to self-insure for workers' POOL A14DIOR SPA Ls
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q () (�,) I have and will maintain workers'compensation insurance,as required by
OU /gection 3700 of the Labor Code, for the performance of the work for which this
Il 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
Q (This section need not be completed if the permit valuation is for$100.00 or less). PrOUT ME 9 'i"f,6�ARY
J ( ) I certify that in the performance of the work for which this permit is issued, Kdoq MIECK, YEE 101-000-439-338 $46.GO
I shall not employ any person in any manner so as to become subject to the CorM;:IUtYtMON FES 101-000419-000 MOO
workers' compensation laws of California, and agree that if I should become MTX?4WHC,CA1,ME--POOL 101- -421-f"O
3 subject to the workers'compensation provisions of Section 3700 of the Labor Mr��;;:�c?�a,��, POOL ta��_t�a�-a�rf„ $45.00Code, I shall forthwith comply with those provisions. M MDW Yf'r-,POOL 101-000-419-000
Date: ppficant•^--^~ 10V
_
"
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 SUR-T ALCC)WT,". UC:°TION'.M.41.D APLAW C � $`�•1�6.$!�
any permit issued as a result of this applicaton agrees to,&shall, indemnify FF17MAY
I�'�= I ,,La ;;& 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 suchpermit, or cessation of work for 180 days will subject permit to cancellation. 0Q �o��I certify that I have read this application and state that the above information is t� IIIIIIIIIIIIIIIIIIIIIIIII 23
• 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 IE
the above-mentioned propert�for ,spection purposes. CITY OF LA OUINTA ' __ - —
EIPT jDATBY FINAN b NALED INSPECTOR
Signature (Owner/Agenf�. � Date 5� * . l• "�.'ref
�. .. ._...to- ....•:. ..i..,,r q.w".:..".yY•r-x.i.... ..-......... -x.....,...-w i......'...a._... ..� �...... .r . .....— .. ... .�...... .....• ... __ ✓ . )'A:. ...�.. ._r...........e.. ...... i - —. .. _ _ __ _—_......_..—._.
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set`lacks 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
Finan POOLS - SPAS
BLOCKWALL APPROVALS steel _
Set Backs Electric Bond
Footings Main Drain 1p/�
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Pibg.Test
Final 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
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)