RPL (9701-004)LICENSED CONTRACTOR DECLARATION
�''k r enalty of perjury that I am licensed under provisions of
U I hereby ". ,., `un..°sith Section 7000) of Division 3 of the Business and
Chapter 9 (com License is in full force and effect.
N Ly Professionals COc Lic. Class Exp. Date
C3
co License #
384460 C46 C53 11/30,97
i Signature of Contractor
Z�f?
6 �, � Date �f_ K -I;,—
..._ -
OWNER -BUILDER DECLARATION
_J (0
I 'fiereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section B&RC. for this reason
LO
C; 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
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.
3
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 7 f'jlr "7 Applicant•"
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1,00,000, 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 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) �� G�' Date 111,1517
BUILDING PERMIT
DATE319�7 VALUATION -J LOT
PERMIT # CONTROL #
TRACT 4 5 G 8
JOB SITE
ADDRESS-��.� 4,V1�i1V111A AitDt�i'lN1l"D APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
IDN''t &B1t LM, D1vMA111 ALT E N,ATIVF. EN.P.:f QY CONCEPTS, MfC.
49-90 A.VE'NIDA MON`CEPC) P.O. F.iOX 564
LA C1U NI A GA 92253 P,E11,M SPRINGS CA 9226MSt
(.613)3244 gffi , C1 L# 2338
USE OF PERMIT
t1t 011
POOL ONLY
i't:`eOL ti,iN )J'OR SPA
13,000.00 LS
tt a r CO. �,t
'ON
cUr�t
18,000.00
JYLAtJ G:ilt%xX VfiEi
101 -OW -439-318
$122.85
"r3N l t; (ra"'C'? ►Ni t rl;
101 .0le,i1.18-("
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+4
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LIrrwTRICAL FT 8— I: X)11.:
101.-V0420rwf►
$43.0)
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��(a1�1.13[Iv+,3.w'�P •�- l3t:H;tL
10'L-(�)t!-41J-iiC)(i
$2J.flfl
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S131`340TA1,, C0N.1"T1tCJC1'ION AA1D 1"1,AN C:EtE-("I . $407.95
LESS PRE' -1 A TM $000
`6'O•PAU T'E32M11 w'CES 01):K' NOW B44l7.X.q
RECEIPT DATE BY DATE FINALED INSPECTOR
L
INSPECTION RECORD
OPERATISN DATE INSPECTOR
6JILDING APPROVALS
Set Backs
Forms & Footin
^mde
s
r;tiEp
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
nrrerall _ Int 1 ath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover 9
Equipment Location
Underaround Electric _
Final I I
Gas Piping I Y
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final 00,
Water Piping
Plumbing Final
Plumbing -Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
FnnAmi datinn
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Fixtures
Main Service
Sub Panels
Exterior Receptac
G. F.I.
Smoke Detectors
Temp.' Use of Pa
I Final
COMMENTS: