RPL (0403-246)49595 Loren Ct
0403-246
LICENSED CONTRACTOR DECLARATION
I hereby. affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business nd
Professionals Code, and my License is in full force and effect.
License e8;# y g f^L,#iic. Cllaass37 . Exp. Date
9/
11-14,
Date ' ' ` Signature-,ofContractor-" +1
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(s ) 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
I 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My wok s' co pensation insurance ca rier &oll'c
Carrier s< uTuIY : Aa no. are:
, i Policy No. s it•d1o„-9 4
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(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' compensatioA provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions:
Date:' 41-Z Applicant k_ /
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
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 City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for/
riinspection
, purposes.
Signature (Owner/Agent) Date
PERMIT PERMIT
BUILDING
! DATE y.^q• , VALUATION U 7.M)AXI LOT, 43 TRACT
JOB SITE 49-595 LORZIi INT CULTR71 APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN 1NEER
'IRA14.9 V1,F_S'1' i 0Ufflk!G INC: C. ta
9968 H BHT 13T WE 102 86.100 AV.gUE. 54
9.A`IDWO CA 92131 C0ACM-32A CA 92M(7dn):3 —9222 CMA 00355
USE'OF PERMIT
!p00L AIM/ R %'A
T6 i'ttRPLltSiTER rNISPE.0 1ION. POOL EQUtI'MENT LMF..IC;►;1URI NOT
INCLUDED 1N. PI Ei 411
017 COMICIRU MOB
:i'MAhR`li' ]JIM, 90MMARY
PLAN CHEK:K1aBE 101.000-439-318 31117.00
CONSTRUCTION 101-000-419-000 $180.00
b' ECHAMCAi, FRE 101-000-421.000
MWHAXICtLITP-P, P00b 101-uC/U-x121-000 $24.00
RMZCTRIt Xf, 139 -- POOL. 1011.-000.420-000 $45,00
D1,t1+sAn51r, 1 ^arj*v, 3u .00939r 1 Ai _0"4-lh 2 ra_AAA 4188.n0
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RECEIPT I DATE I BY
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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 qp
Footings
Main Drain
iBond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping 7
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 - 5
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: