RPL (0311-089)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty°of perjury that I am licensed under provisions of
Chapter 9 (commencing w.�th Section 7000) of Division 3 of the Business and
Professionals Code, an'd my License is in full force and.effeet.. ! -- t
License # + Lic. Class �Date ( t
Date Signature of Contractor
f
OWN ER -113 UILDER.DECLARATION
I hereby affirm under penalty of perjuryjthat I am exempt from the Contractor's
License Law for the following reason: �11-1
( ) 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,-Bysiness &.,Professionals
Code). `
O I am exempt under Section /B&P.C. for this reason
Date Signature of Owner % 41/1,`#q iiNt'PI'
{ ,• �r�
WORKER'S COMPENSATION DECLARATION''•/7
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 workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit'
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 with those provisions.
Date: Applicarit ~���+'`�� t,::" �
Warning: Failure to secure Workers' Compensation coverage ,i s�nlawful and
shall subject an employer to criminal p a ties 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
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and,Sfaaie laws relating to the building
construction, and hereby authorize representatives oh this City to enter upon
the above-mentioned property forinspection purposes
Signature (Owner/Agent)
BUILDING PERMIT PERMITH
(33'! 1-WJ
DATE 1.1114l74X VALUATION S24PIMM LOT TRACT
di
JOB SITE 25, 1
ADDRESS 434;_�:_;IWLAN ml ulzr
APN
..
OWNER
CONTRACTOR/DESIGNER/EN (NEER
GERA)MO 5EC` LTRA
OWNER ^ B UT.DR
43.875 YVfd." OOT3R*r
Y L.AQUUM CA 9,,253
R CIBI A jj1 j
USE OF PERMIT
POOL. AND/OR SPA
POOUSPA, A.1 ARMVIIARRIISRUS SNa1LL BE IN Pt..ACEAT p1;.L+•PIASTRR
INSPECTION, +EQUIPMENT ENCLOSURE NOT INCLUDED.
POOL AEaiEWOR SPA 1Q9,640,00 I's
FIVIMMIMED COST or CONSTRY7C"Y ON
24,(9)0.00
IPER1 AT YFX SUMMARY
PIAN CHECK Y1 E 3(i1-000.9»t9.33z� x(57.95
CONSTRUCTION FEE 111-000-4.1E-000 $7.43.00
M) t",iFIA:NICAIf }KE.., POOL 101-000421-000 $24.00
ELZCTRICALYUr.POOL 141-000-420-000 `I45.00
._._...PLUI D1140 FRI a -• POOL 101 -000 -419 -OW SY1.0
� D `
NOV 1 7 2003
Ff
CITY OF LA QUINTA
FINANCE DEPT.
STJB-TOTALCON`VLgI^N AND P VCII /K
Y496'.9 5
i.. F 9S PRE -PAID I;�KEU
$0.00
TOTAL PEMM" YKES DIM NOW
$451695
do
RECEIPT
DATE .7
BY G
DA FINA
''��..
INS P CTORr
IL.
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 Bab!cs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Finan,....,
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
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:
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