RPL (0104-269)53305 Avenida Madero
0104-269
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (corn-riencing. with Section 7000) of Division 3 of the Business and
Professionals Co'de, and my L"ic-brise is in full force and effect.
License #
Lic. Class Exp. Date
,Date Signature of Contractor) ^ L
'd
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from.the Contractor's
License Law for the following reason:
( ), 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure isnot intended or offered for
sale (Sec. 7044,.Business & Professionals Code).
1, as owner. of the property, am. exclusively contracting-! with licensed
contractors to Construct the project (Sec. 7044, Business & Professionals
Code).
O Lam 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: proOided 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
So6tiQn 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.
ST.K4118FUND I8420"-00
(This sectioh:need .not be completed if the permit valuation is for $1 .00.00 or less).
:-(, )-'l`-.c,ertiiy".ihat in the performance of the work for which this permit is issued,
I shall,.,noi employ any pers6n in any manner so as to becrxe-subject to the
.-work6is;&m'pensation laws of California, and agree thaV'if I should become
I
S6bj66(to,the workers' compensation provisions'of Section 3700 of the Labor
shall f6rthwith comply wA those provisfons.
Date: "-I Applicant Za I/
Warning: Failure to secure Workers' Compensation coverage is unlawful an
Shall subject an employer to criminal penalties and civil fines up to $100,000,
addition t , o the, . cosf of compensation, damag6s as provided for in Section 3 i
O
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and'Safet
for a permit subject to the conditions and restrictions set forth -hi
application.
1. 1 Each person upon whose behalf this application is made & each person a
whose request and for whose benefit work is performed under or pursuant t
any permit issued as a result of this applicaton agrees to; & shall, inci6mnif
& hold harmless the City of La QiJinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and nd 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 tq.comply with all City, and State laws relating to the building
constpAction, an&hereby authorize representatives o J, is City to enter upon
tXhebove-mentiohed prop'dhy for inspection purposes.
v
i nature(Owner/Agent)U A— Date Q
V
WILDING PERMIT PERMIT #
.DAT -,-- VALUATION LOT TRACT
MAX) M_
G4t?4a0C
JOB SITE APN
ADDRESS
.n.ms
OWNER CONTRACTOR DESIGNER ENGINEER
CORONFL, COIN 1131MU
7 t -, is o cm.al ww1co, iZTrr_run,3.o 76.1 ti 0 CAMETT&MPIC0 OUTIRN42.4o.1
I.A. QVIN-rA Cts, 92253 LA Q: UWA C,1A 92253
(760)564.-4604 r_73,vi 2261
USE OF PERMIT
P091, ATINOR VTA
PCIOWSPA aHLY - AIARhISIBARMERS SHALL'U, IN KACE, AT
AIR&PLAWFUl INSPECT101* POOL RQUIP.WNT 010. MURK 19 NOT
IMCLUI)FV. TW THIS PEXMIT.
POOLA14DIOROPA R1090100 U31 -
Y., S If 1B M I F. P C 0 S 1, r .011 P11 OR W I R, v C 37 0 N
PFRMH,'F.EF 9MMAT&
PtAN CHEI,,32. IT% 101 -OW -439-318 $6413S
c.- 115 ME 101- , 000-418-000 099.0
MEP,H"WAL FSE -- POOL 103 .000-421,000 54100
J.?FXCTR1VdU, P10 - POO -t 101:400-420WO P5.00
PLUME1, 40 "19 __ POOL 100 -.04 0.41 M00 ST)"04
APR 2 4 200i
1
CITY OF LA 90940TAL. (Y.) 1,8111RUCIAOX MD RAW clMr-M
FINANCE DEPT -f Wsm
t.
117TAL PERAMMS DUE.11R.1w
RECEIPT I DATE
BY /, / I DATE FINALED
A
$25935
$0,00
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Steel
Electric Bond
Main Drain
�!
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
Final
Gas Piping
�� �-
PLUMBING APPROVALS
Gas Test
Vol
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
iit 111
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)