0103-041 (RPL)77240 Loma Vista
0103-041
LICENSED CONTRACTOR DECLARATION
1 hereby affirm under.penaltjof` pe'rjury that I am licensed under.provigions of
Chapter 9 (commencing with Sect& 7600)6f -bi-visiiori 3,of,the BusinAs arid'
Professionals Code, and my Licenge-is i'n full force and effect..
License # Z Lic. Class Exp. Date
100 012(
'/6ate,') Signature of Contractor
OWNER -BUILDER DECLARATION
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 I
1, 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:
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
S6cti6n 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.
41TAT9 FUND 22949 UNIT 0021PID
(This section need not be completed if the permit valuation is for100.00orless).
I certify that in th6 performance of the work for which this per i mit is issued,
I sh ll 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 provision
Date: P—A
Applicant—
/Warn4ing': Failure to secure Workers' Compensation coverage is unldwfuNnd
shall subject an employer to criminal penalties and Civil fines up to $100,00d in
addition to the cost of compensation, damages as provided for in Sectibn-3-706
of the Labor Code, interest and attorney's fees. I
t
IMPORTANT Application is hereby made to the Director of Building and Safelft
for a 'Permit subject to the conditions and restrictions set forth on 449 0
appli6ation.
1. Each person upon I 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.
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 properly for inspection Purposes.
.ignature.(Ownei
,/Agen;)-- /;N/ Date -Lir
v
>-BUILDING PERMIT PERMIT" '
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS r I
APN
I
I
771-2114 LOMA VISTA
OWNER
R
CONTRACTOR DESIGNER
M7 5 -
73 9 6 0 IMEMAY 111, Wh,
4A QVINTA CA 92259
PAUA 1) W-KRT CA., 92260
5220
USE OF PERMIT
101YUR, UPA
VC-01.&TAMEQ jkNSY =31AWKI ALAPIMSAARR190 S",,L BE IN
PIACE, AT PMP1A3'h%R, N3M11014. P601, EQUIPMENT raicwvng
POOL ANDIOR. OPA Lo,
F.V11=11VI, I COSY OF COM-MC1101K
1710IMM
PLAN CHECK FEE 101 -000-439-3 18 41111.66
Cown'n"vefum pip"
MECHAMCPA, FrX - - PO("X, 101»00-421-000
PV001 101 -000-42D-000
P03110DICIFEF, - P061,. 1Cil 000-419 000 rno
MAR 07-2001.
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SUB -T MAL COMMUM10HAIWO P1. ". CMICK
91.00
NIBS M-PAMMS
S0,00,
RECEIPT
DATEJ.
BY
INSPECWR '
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
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 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
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
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: