0006-200 (RPL)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty of perjury t hat |omlicensed under provisions of
-Chaptero (commencing with Section 7000) of Division of the Business and �
Professionals Codo.'a�dmyLicense iain,vn�mu'o
aonVeo��
License* ` o�o/�m',�~` e*��b�.
. .
ate Signa ure 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:
1;'as'own'er 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).
1, as owner of the property, am exclusively contracting with ' licensed
contractors to' constr6c.t the project (Sec. 7044, Business & Professib'6als
I am exempt under Section B&P.C. for this reason
WORKER'S COMPENSATION DECLARATION
. . `
| hereby affirm under penalty of perjury one of the following declarations:
( ) | have and Will maintain acertificate oxconsent mself-insure for workers.
oompenoauion, as pmmdod'fo, by Section 3700 of the Loun, Code, for the
. podthe x tmapermit ioissued.
`
! ('> | xmmand will maAnfainworkers' compensation insurance, morequired by
'Section 3700 of *the Labor Code, for the performance of the work for which this
`permit is ioovpd..My workers'. compensation insurance oanio, & policy no. are:
Carrier Policy No.
STATF. FOND
(This s6ction.n-eed not be completed if the permit valuation is for $100.00 or less).
( ) .1 certify that in the performance of the work for which this permit is issued,
.1 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
Cole, I shall forthwith comply with those provisions..
Wairning: Failure to secure. Workers' Compensation coverage is unl6wful and
shall subject an employer to Criminal penalties and civil fines up to $100,000, in
addition to the -cost of co ' moensation, damages as pr6vided for in Section 3706
,of the Labor Code, i�i&est and aftorney's fees.
IMPORTANT "Applic�'tion is.hereby made to the Director of Building and Safety
Jor - . a permit subject' -to the . conditions and restrictions, set forth'.on his
app, ication.-
1. Each person upon whose behili. this appli6ation 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.
'n.Any permit uresult uf this application becomes null and void if
'wmm is not commenced within 180 days from date of issuance of such
ponnh. or cessation ofwmmfo, 180 days will ou�o�pennhmoonnoUaUon�
~ ~ .
applicationI certify that I have read this d state thatthe above information i
correct. I agree to comply with all City, ana State laws relating !9 the building
6oh ' struction, and hereby authorize representatives of this City,to enter upon
.h--�,.'m_----property
(Own)[61 BUILDING PERMIT
,DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR DESIGNER ENGINEER
UA. ipA 92253 P"MKRT CA 922.60
060)340-9000 CK0 355
USE OF PERMIT
,NT FOR POOL EQUIPM T
E14CLOSURE IN THIS PER -MIT.
VALUATION 1 �%300. 00 LS
JtSrD"TF.D COST OF C0X&7rZVC_`F10X 1" 00.00
PERM- FEN 9(A0&&RY
PLhN CHECK.rEE 101-000-439-318 $111.15
CONSTRUCTICYN "IE 1101-W0418-000 $171.00
MECHANICAL PE 9 -- POOL 101-000421-000 $24.60
PLUMBING FEE — POOL 101-000-419-ODO . $27.00.
12,33 PREPAU)FM9 $0,00
ow
Ora -5 imn
RECEIPT .11�. DATE BY DATE FINALED INSPECTOR
er/Anentl
-_--_�------
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
Extenwr Lath
Drywall - Int. Lath
J
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
zA
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulations
c�
_
Gas Piping
Gas Test
Appliances
Final
p0
Com` v
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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