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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I an, licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
��� 656128 33 nlIL c-Ff jO12311W
/Date Signature of Contractor AZAA At"r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 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).
( ) 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:
,(f) 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.
I 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 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 Secti n 3700 of the Labor
Code'
.I hall fort with comply with those pro isions 1, .
V Date: Applicant_f "
`zr w r
Warning: Failure to secure Workers' Compensati n coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
�r
IMPORTANT Application is hereby made to the Director of Building and Safety
_for- a permit subject to the conditions and restrictions set forth on his
application.`
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
,any permit issued as a result of this applicaton agrees to, &shall, indemnify
e" & hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby auth'orize representatives of this City to enter upon
the above-mentioned property fo"r, inspection
pWS0_
Signature (Owner/Agent)
rDate.
BUILDING PERMIT PER ITN
DATE VALUATION LOT ���"��,�#, TRACT
yy
1V8�y'IPIIMIe4Y[� .s9 -�
JOB SITE
ADDRESS
APIN
DAMIJURM DOM
OWNER
CONTRACTOR / DESIGNER /EN 1NEER
CIYtiJZ yNMgM, COMIUATAVO
wl7wO1NM pN001.9 & STIAS Cf !g .V" C01
It'llBMTMUM) CA 92409
PAI;bl:1•;i11. X08FRT CA 92260
(7,--)0) 0-9CM Cts oft, 355
USE RM ITy
fOppFg�PERMIT
-E144/ �Mshy
R SPA,
f+'•tDC!lAPA. ALARMSIBAR U S),IALL HE I N I✓LAL,kE ,A r P,1L&PLA.ST&R
Ci+ SPECTICN. POOL WQUIt'AAL--9�i7 YNCLOSURK NOT INV4?,1tli ED.
WrOP$AM) COST OF'C'ORSTFI.�dC.`�".�OH
103.000-439.318 $1 M70
W:'C�VISTRUCTION PRE 101-000-4181-000 $109.00
MECHANICAL ME - POOL 1,01-000.421,000 $24,00
)FIXCIVCAL R2 -- POOL 101-000-420-000 $4100
fta UBINO PW? •- POOL 101.000.419,000 $27.40
- a ; , — '"Y'MON AND I%.W CHECK
i� IT -1 -Tai-
:022.10
AUG - 200 Y10S:Dap, POVY
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RECEIPT
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By !
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DATE FINALED
INSPECTOR
a'.,
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drains
-
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
2 f
f�G 12.1
Waste Lines
Heater Final
_
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
j+ �
Sewer Lateral
Pool Cover
V (—
Sewer Connection
Encapsulation v
Gas Piping
Gas Test
Appliances
T(/
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)
79769 Dandelion Drive