RPL (0301-002)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
t f70Cit3i'b E'-33 1it/3)121
Date J, ' 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
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 FWPT-:4K9-D31i6L Policy No
(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: 11? LL'; '; Applicant 1h4.1 r : Pr,
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. w -
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) �� r ' frit "� f� Date
1
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 03 A TRACT
/1,-`,
0'7 17. M-318-7
JOB SITE
APN
ADDRESS
.y.1)
iB�a
OWNER
CONTRACTOR / DESIGNER / ENGINEER
81435 MIJ.W'°r-AMUD`V;ZCA AGR
4688 NTOUN COVl DRIVE,1494
LAQIMTfA G.A. 92253
;N% IK.41 VnW.2 r1k 92210
(,760>345-1316 MIA €697
USE OF PERMIT
l±°MAJ,111 TWOR 30A
P001.y SI+.a,., ilei f TE 2.b'.A1,L. ALAR-MMAMIZIFIVS SHAIL BF lAt PLA .P -.X
PRE -PL A,S "ER NUP�c;�;Clt�K EQUIPMENT 1;NCL:�3�UNOT
13ICL.til;?1�i1.�'i).'�G;I�1..ACPJFJliQ U14?�7LPR SEPZVt.f�iZ Fri: RMIT.
( �
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A
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Pool, mrwlm spik IU01100 U9L�N
0 2 2093
IL
OF LA Q A
IHA.NCE DEPT.
lre 'L.RMU FRE. SUMMARY
PLAN Gl-1ECK 1789 101.000-439.318 S1205
CONSTRTJCTICYN F? 101-000.418-0.00 118.00
M WHAN1CAL FEE -- POOL 101-000-421-000 $24,00
X1..M.TRICX1,1iM • W POOL 101-000.420-000, 113.00
I'I: UMBIN10 FRE, -- POOL 101.000-419.000 �3 i�-0
r RM TC9'i,'AI,Gb1` 071MCM0111AND 'P1 C-.EiiWCF,
$407.85
1 4 PF �F�a?177 FE
$0.00
TOTAL F'YM TrFEES FYUR IN G°f%i'1i'
RECEIPT
DATY
BY .. ,>
DATE INA D
C OR
1J!VR
//
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
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
0
Final
Gas Piping
VPLUMBING 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
_A�
Gas Test
Appliances
Final
d
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)
C/cOM�MENTS:
�94
E
V! - v� LAee-TITY OF LA QUINTA SUB-CONTRACTO LI �'%�
ST
JOB ADDRESS r PERMIT NUMBER .02-07-11 OWNER JV/ZF_ JErSKr� BUILDERThis form shall be Rosted on the Job with the Buildina
i rd all i ous lac . Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to comm
of building permit. For each applicable
Trade /Classification
encement of work. Failure to comply will result in *a stoppage of work and/or the voidance
trade, all information requested below must be completed by applicant. "On File" is not an acceptableresponse.
Contractor State Contractor's License Workers Compensation Insurance City Business License
Company Name Classification License Number Exp. Date Carrier Name Policy Number Exp. Date License Number Exp. Date
le.g. A, B. C-8) Ixxxxxxl (xx/xx/xx) (e.g. State Fund, CalComp) (Format Varies) Ixx/xx/xx) Ixxxxl Ixx/xx/xx)
EARTHWORK (C•12)
CONCRETE (C-81
FRAMING IC -5)
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10 �.
660
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6
STHUCT. STEEL (C-51)
MASONRY (C-29)
PLUMBING IC -36)
'LATH, PLASTER TC -35)
DRYWALL (C-9)
HVAC -IC-20)
ELECTRICAL IC -101
ROOFING (C-39)
SHEET METAL 4C-431
FLOORING IC -15)
GLAZING IC -171
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INSULATION IC -2)
SEWAGE DISP. (C-42)
,PAINTING (C•33)
:CERAMIC TILE (C-54)
CABINETS IC -61
FENCING (C-13)
LANDSCAPING (C-27)
POOL IC -53)
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