0206-093 (RPL)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
656128 C`5.3 W "r -6 10/31/2(
Date j��'!r% Signature of Contractor f,Y&t Zer � /W
VI �
OWNER -BUILDER DECLARATION s
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 declaration's: '
( ) 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 S'f'ATIr C;OA4PF',4SA TI Policy No. te4 00R�ldiY-f)$
(This section need not be completed if the permit valuatiori 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 th6se provisions. F+
Dater - > Applicant
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
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building aha S ii
for a permit subject to the conditions and restrictions set forth on s
application.
1. Each person upon whose behalf this application is made &eachpers at
whose request and for whose benefit work is performed under or pursua t to
any permit issued as a result of this applicaton agrees to, & shall, inde
& 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 fof`nspection purposes.
Signature (Owner/Agent) Date' =N`
•.•-ZUJLDING PERMIT FERMI; _
DATE VALUATION 33-0 400.100 SLOT' 40'
TRACT
i l =1
JOB SITE ADDRESS �C.+ 1�7 � Y^:lydASJC APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
T. D. i ►mak i'IF DrNYE ..03>l"r L''A &O -AW, I?C OL S & ,S U4 iyITOP 1b4tNT CO.'
P.O. BOX 1716 7472 JO_KIDWO,, SMITIE#A
TA Q11IMM CIA 92253 PALMDERV C.r`i. !)2 60
(760)340-94000 CBW 00355;'
USE OF PERMIT
POOL MYCR EPs.
PtJt?i.r'S.P .. UBQ ANSI Tal-ig-1995. 6 iLfr S:' BI=K ?w''Y`AZI , CITY >
: TAIRf%AWD ,AL1.ZAMARRIN"RN SHALL SL IN PLACT f5lUNt 10
PI1&NL?,&9R INSPECT IOU. POOL :Ei�uiPA+i.lJnr eNcL4Jvi7RP,voT
f-P"Cdt>LA1'dD,YOR SRA I.0
„tFc
PLA14 CI�F:t`1r ,F�i:1� 101-000-439.315 SIMI$$
CONSTRUi:' KON FEt 101.000,41.8.000 $3ft'8.60
ELLCTIL AL.FBE -- .POOL 101-000.420.000 $45.00
PCrCi1d€13 NC FF,,E -- .1:G` oij 1 .1014 -op -0-419-000 $27,00
A ,
ll.l N 13 2002
CITY OF LAQUIIi -
Sn..
rAL CONVIRUMION AND PLAN CI -TICK
47?;6i7S9.z;�fl➢
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1 i t:xy"�irl b:"r
RECEIPT DATE r BY DATE FINALED INSPECT gr14`'
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
Steel 2L.2
Set Backs
Electric Bond — 2 —
Footings — _ p
Main Drain d
Bond Beam
Approval to Cover
Equipment Location z—�I
Underground Electric 9— d
Underground Pibg. Test $7 —0 �
Final
Gas Piping 7-- 'D —
PLUMBING APPROVALS
Gas Test — 7 -caLCS
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 —per
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)