RPL (0201-177)78205 Masters Cir
0201-177
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 iii.full for6d',and effect. J
License # Lic. Class Exp: bite"
Q, 3
Date/ Signature of Contractor_
OWNER -BUILDER DECLARATION
.1 hereby affirm under penalty of perjury that I am exempt from the Contraictor'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. is'not 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 ;
O -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'
com.pensatipn, as provided for by Section 3700 of the Labor Code, for th6
performance of the work for which this per&t is issued. i
( )')(have and Will maintain workers' compensation, insurance, as required by
8ectidn 3700 of the Labor Code, for the performance of the work for which, this
pe . rmit is issued. My workers' compensation';insurance carrier &- policy no. are:
Carrier Policy No.
6 1AROND011 WATIa
(This section need not be completed if the permit valuation is'for $100.00 or less).
certify that in the performance of the work for whiclitthis permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, land agree that if I should become
subject fo,the workers' compensation provisiomcifySection 3700 of the Labor
Code, I shalhforthwitb comply with those provisions!
Date':.11 2Applicant
Warning: Failure' to secure WorkersCompensation 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 Directbr of Building and Safety'
for A permit subject tothe conditions and restrictions set .forth on his `
Application.
-1. Each person upon whose behalf this application -is made & each p4rson of
whp'se'request and for Wk6se benefit work is performed under or pursuant to ;P_
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 it Any permit issued as'result of this application becomes null and void if
. ork is not commenced within 180 days from date of. issuancOof such
permit, or cessation of work for 180 days will subject permit to'cancellati6n.
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 inspection purposes.
Signature (Owner/Agent) Date
BUILDING-RERMIT PERMIT#
VALUATION LOT TRACT
,
r
JOB SITE
APIN
ADDRESS
7&.,?,(4 NASIEERIS CIRCXX
;OWNER
CONTRACTOR DESIGNER EN (NEER
6135 MIX;? CANY ON 1OK
^14 8 5 2 XbTR 014 IPS
.-RAUA DWZ43T C.A. 922.61
-1
MIA".0M I Cp. 9221,
'684993
(7f' )- .5 _51 I! rs
USE OF PERMIT
COL ,k=/OR k.
AT 'IV.,0_9 -.1KQ1A'PtV1 114T 0'.0 0C NOT
INACLUMD.
POOLANDIOR SPA 4000A)0 L f
F-IsMaxl= cos -It my CaNNIMUCTION"
RIMAW VIM MWMAKY
ci i L c Y, PAY,
CQNSTRUCTIOU AM
Mb l:jc't.sANICA),, VIC, ?I ^ Pool" I Olt _00042 1. »Ooo
POOL'. 101 -600420-000'
PLIHMNO FUE POOL 101 -000-'4119-000 %,a
J
JAN
C QUBPIT
PA
A V*,-
sc'n"'.68
X, I pw ?,n-
$0.00
TOTAL PEWAlf FEEND OE NOW
RECEIPT
DATE
BY _-7-1D
EIFINALED
v
INSPEC X IR
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
r ..BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Beck% :
Electric Bond
Footings ,•
Main Drain
Bgpd Beam
Approval to Cover
Equipment Location
Underground Electric
_ t- - O
Underground Plbg. 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
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)
rj /
Final
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