0103-120 (RPL)LICENSED CONTRACTOR DECLARATION f
U) I.hereby affirm under penalty of perjury that I am licensed under provisions of
`F— Chapter 9 (commencing with"Section 7000) of Division 3 of the Business and
W Professionals Code, and my License is in full force'and effect.
O =)ch License # .Lic.•class Exp. Date
i
&Z Dat Signature of Contracto �.J
x:0,.0
J V coo OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
' F d License, Law for the. following reason: t
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). .
(. ) 1, as owner'of the, property, am exclusively contracting with licensed
4 contractors to construct the project (Sec, 7044, Business,&,.Professionals
Code).
O I am exempt under Section B&P.C. for this reason
O N Date'" _Signature of Owner
rn
WORKER'S COMPENSATION DECLARATION !
d Z
C) CE: I hereby affirm under penalty of. perjury one of the following declarations:
U-) FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w LL compensation, as provided for by Section 3700 of the Labor Code, for the
O' J Q .. 4 pe"rfo�mance of the work for which this permit is issued.
m Q U (' ) I have andemwill maintain workers' compensation insurance, as required by
Se
tion 370o%of the Labor Code, for. the performance of the work for which this
'n- Lo perrnit is issued. My workers' compensation insurance carrier & policy no. are:
Z ;Carrier Policy No.
r-' O ' n,
(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
J workers' compensation laws of California, and agree that if I should become
Fat
'ct to the,workers' compensat o ovisions of Sectio 3 00 of the Labor
, I shall forthwith comply with' oseJpro i�or}s'0'4 Applicant .• f{/" i'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000in
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
6 &' hold harmless the. City of La,,Quinta, its officers, agents and employees.
r, 2. Any permit issued as a result of this application becomes- null and void if
workYis not commenced within 180 days from date of issuance of such
t 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
r`• ' correct. I, agree to comply with all City, and State laws relating to the building
construction, and hereby authoV1 representatives of this City to enter upon
:he dove -mentioned property Sr ifispection purposes. f
gnature (Owner/Agent) •�t� Date
c
BUILDING PERMIT PERMIT#
DATE ' LOT Qtl� TRACT
VALUATION119,02435
_ } {
JOB SITE ° "'
APN
ADDRESS 13-W. JDAM0R, A1WG•STAR;:O'rfW-r
-
OWNER-
CONTRACTOR/DESIGNER/ENGINEER
C"1 3.�1"CC Y CROM-11
011)0 1-Fl,`E?, 42.05?
74-725 r0MD"MY9, AJ,
9,01 BEVIUW- 1.t+T0 C"A 97..• 08
PAIN ASIS T 1111k 97.260
MIA 5386
t
USE OF PERMIT
POOL AIMM EPA,
.A1JkRMSA1,P RRf2i'W :fHAXJ, Ar IN PLACE 'we 1riW111.: OF
PR&PLl1S`.{ER. lN3PEC 1014.0 I. F. OP V, HIGH BLOCK WAUA dtTY
FSTANDAMM,
P100LANWOR;'ORA 191M.100 US
a t,tf, WALL 1.3.f)13 11F
_ FS-Mc,a r GOST all' C"0.l�tt�"i�'�UC1t70 1
PERINT ME 910AGW' OV,
1!'1<AN C112CK FEZ , - 101.000.439.318 $13A.53
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;€Rl~{;}•iAN"ACAL FZF °-1'001, 1101 000.4ZI.000
ltai -f;e� 2Str LitT 'I' i3.GU
Xi.•1?%sT1t.Bf.',,AL F10 POOHX.
�1�iS?i 11�f�i£ - OL?,L 1 riRilt�tl ),9<t1�3a X17.00
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U20 J•'REePAIV-`FM
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TarAJ.,:s:9: WWTITONS DUE NOW
RECEIPT
DATE
BY' ;
DATE FINALED
INSPECTOR
,
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
Set Backs
Electric Bond
Footings
Bond Beam
Final
PLUMBING APPROVALS
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
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
Encapsulation
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
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)