RPL (0309-246)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
6561.28 C53,14,16 4••8 l013.1/M w
Date ,. Signature of Contractor -
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
contractorsto construct the project (Sec. 7044, Business & Professionals
Code). t
{) I am exempt under Section B&P.C. for this reasons
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.
J7-f'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.,arg:
Carrier STA E COMP NRATY Policy No. I>Rt�4- 154-29131, .
(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 l should become
subject to the workers' compensation pfovisions of Section 3700 of the Labor_
Code, 'l shall forthwith comply with those h ov,Icions.
Date: �r Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
for a permit subject to the conditions and restrictions •set forth on his
application.
1. Each person upon whose behalf this application is made .& each person at
whose request and for.whose benefit work Is performed. under or purs
any permit issued as a result of this applicaton agrees to, & shall, indIr
& hold harmless the City of La Quinta, its officers, agents and empl2. Any permitissued as a result of this, application becomes null andwork is not commenced within 180 days from date of issuance opermit, or cessation of work for 180 days will subject permit to canceI certify that I have read this application and state that the above informacorrect. I agree to comply with all City, and State laws relating to the b
construction, and hereby authorize representatives of this City to Ieni
the above-mentioned property for insspjectio/n�puurr`pose's.
Signature (Owner/Agent) /' sF- J` Date
PERMIT -.
'BUILDING
PERMIT
246,
DATE '^ - -VALUATION,. .- "' LOT_ TRACT .�
JOB SITE L�
ADDRESS ��� 1Y,�LI�� �A�RE ,1.il� •, . ..
API
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
T1). D RT DEVn0PMM1n1..:..
CA.ie[FC)RWA.PI OLP AS (TOP MAN CO
'P.O.. BOX 17 16
86-100 AVENTH 54
LAQUWA CA. 92253
+_'OAC 1InLA ..CA 92236
(7.60398-9222 • C_ 00 355
USE OF PERMIT
POOL AM/OCL SFR.
P001J. PA,'SBQ,.AHr) f?]RPPIT, 3 L It.V 1•i10H I•SLOCIC-W AJU
ALA1I. d8h3ARIiIZRI$ SHAD BEM PLACE, PRIOR TO ,PP04 PLA a'1IR '
;INSPECTIOW ,
4 FT, WALL ,.411 ISP
FC401, AIS WOR SRA
�S�S"�1 mxrEI3 OOsr, or, C.`OIa b� 2ii on
DaOtD
]PFAMIT FPsi SUMMARY
PL -4111 CHWIX I?EK_ ; ' . 1014000.439.31 i§ . $128.70
CONSTRUCTION iELP $199.00
'
Ill XHANICAT, NIRE .. POOL 1014000421=000 $24,40
FLECTRIC,AL FEE - POOI, . 101-0,%1.1:201 000 $0.00 .
PLUYe 81..110 FE �� POOL',, 101-400-419-000 $27.00
°1C1'�'Ai. G"•f3m;�''t7tt,ip-no23. NT3:i-pi fiS� C i
SS PF:iiP�'.a,?D Fn
$0.00
..� •
fit. �7•� 1-C �•t1yp�
r TMAAl.X".1�.1T.d�/1L►�`.L'S:�EsA9.Y�Td&n.l`Ii;a7Y
,d. ��y.�•� y�
$42:i. 0 '
EP 2 5 2003. =
iTY OF LA QUINTA ,
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
A2 A0,25141
INSPECTO
RR,
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
steel
POOLS - SPAS
-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
a
Underground Plbg, Test
Final
Gas Piping
f PLUMBING APPROVALS
Gas Test
Electric Final
V 7-3
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
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: