MISC (0112-003)78185 Masters Cir
0112-003
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 and
Professionals Code, and my License is in full force and effect. .
License # Lic. Class Exp. Date
x:531'4 .11 AU
Date 1 * ?ill Signature of Contractorf "'•,"
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:
() 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
Sect on 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 STATE C'C9M1 ENSATk Policy No. 04006162
(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 Section 3700 of the Labor
Code, I shall forthwith comply withathbse provisions.
Date: 4 Applicant d .. Zi =,
j es -
Warning. Failure to secure Workers' Compensat on 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 foq inspection purposes
Signature (Owner/Agent) . fT <' Date
DING PERMIT PERMIT#
DATE VALUATION LOT Q}.ESl dr Z TRACT
JOB SITE
ADDRESS
OWNER
CONTRACTOR /DESIGNER / EN (NEER
00,11TVMA DEVYI.01" t'EM CGRA'!,
CIUKHRIUAPOOLS & -Ag f, 011 MAN COi
7W499 WOLF
'7471.5 JONIDRIVE, MMTOA
1✓'AUA.0F.NRr<r CA 92260
1~PLM. DMIIM 'C A 92260
'36f ;f:39d 9J ➢PJ f,:` 3Y.a4 33
USE O,(F((PERMIT
9{,•
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laOM.laNWOR SPA 00,(10.1
PLAN 01WPX i?NE 16-1 w000439-318 W.10
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RECEIPT
DATE
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BY
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DAT NAL
INSPECTOR
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PLUMBING APPROVALS
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
/OPERATION
Water Piping
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Pool Cover
Underground Ducts
Sewer Connection
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Final
Combustion Air
COMMENTS:
Roof Deck
Exhaust Fans
Utility Notice (Gas)
O.K. to Wrap
Temp, Power Pole
F.A.U.
Rough Wiring
Framing
Fixtures
Compressor
Sub Panels
Insulation
G.F.I.
Vents
Temp. Use of Power
Fireplace P.L.
Grills
Utility Notice (Perm)
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
Steel
Electric Bond
Main Drain
POOLS - SPAS
J
_I l
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Approval to Cover
Eauioment Location
PLUMBING APPROVALS
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)