RPL (0403-394)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
X65 128 C33 MC nZ8 0. 131 A.,t
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
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—
Sebtion 3700 of the Labor Code, for the performance of the work for which this i�"
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
STATE OOMPE31SATI t -46-6168-a".
(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 prov cions of Section of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant % r
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. I N
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 employe s-
2. Any permit issued as a result of this application becomes null and voillip,
work is not commenced within 180 days from date of issuance of suThJ
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above informationLn correct. I agree to comply with all City"and State laws relating to the buildi
construction, and hereby authorize representatives of this City to enter up
the above-mentioned Property
/for inspection purposes.
Signature (Owner/Agent) a�./j>r �'%�''1'-< Date'
` • BUILDING PERMIT PERMIT# /
V
DATE VALUATION ' LOT 0110^ x.94 TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
T.D. DME IME MPMRr
CKALIT-ORNIAPOt"!. `L IS . , V% (101) ;ti!tM ('03
P.01 BOX 1716
86»100 AVENUE 54
'L&Q AA. CA 92253
C;fJACHELLA CA .92236
1;7003398-9222 aBlii 00355
USE OF PERMIT
x'001- ARDIOR 113P
POOL &SPA. L13Q ANSI 21.38.1999. AL.P'cF;IAS 1fi.P.RPJEP.S SHA.LL BE
111 PLACE I'WOR TO PREPI.AMR INSPECTION,
K)MA`±•dDIOR SPA 1910±*►8.O^ .LS
cowl, or
:19, .0€4
PERW1:, FA& KcrAdx, ARY
PLA13 CHECK FRE 101-000-439-3538 $123,771?
C:f1`NSTRUc` oi-i Huh , 101-00 0-418-00 $198.(M
143P<CHAMICA6 FFE -- POOL 101.000.421-000 524.09
ZLRC'1'1.HCAL1 FEE.. POOL 101-000-420-000 $45.00
PLUMB1140 It1?L -- POOL 101-000-415-000 $27.00
SL3"SftYi. taL C',OX.cSr LYC' 11ftitT AI%T]) P 1 C°IIT,CK
$422.70
1X45 Ilm-1 AI a T.V3
s.c%1D
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TMAJ. i>EMMJT M 8 DTE NOW
VIT2,70
MAR 31 2004
CITY OF LA QUINTA
rn'+c n. n1A C_ r11C.
EiPT
i1
el
BY
DATE ALED L/
INSPECTOR
/I
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
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
--
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: