RPL (0211-023)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under pro�,Ysions of
Chapter 9 (commencing with Section 7000) of Division 3 of:the:.Pysiness and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
V313 1/2-C
Date +'t/i^{�"1 Signature of Contractorf
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 31TATTEPUNO Policy No. 0461046702
(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:I`3- -c Applicant rrr7<ar
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.
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 nu). and void if
work is not commenced within 180 days from date of isslsf ce 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 inspeefion purposes.
Signature (Owner/Agents"� �'r Date
f ' f yrs
f` PERMIT #
TANG PERMIT
DATE .. /w�nl'ION'tp LOT TRACT
F
JOB SITE
ADDRESS g�-Z�AT�tiSrGbTY Yt1yair
APN
-
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M PAY C If
131 INYMM"M MaLZ &MAS
DiON CT DRMCAR`1 1,
10,0. BOX. 1791
1111VINE CA 92606)
LA QUNTA CA 9W.1
USE OF PERMIT
ANDA)IR SPA
POOL &SPA ONLY, ,etLARM&;ff3AP.PJZRS SHA11 aX IN PI.1?CM PRIOR TO
P1REN ASTIM t SPECS IOR, POOL .rIQUIPMM T t 9CLOSU RF. lrtt;71' MCLlJlDED
P00714Ah]E?fCA BRA 14009100 U
C0611 OF 00,11 91R.ILTts',iION
131M0u1M
�.�.R1�RIMNalo
d.d4'f,�1tl7.�, 3:I3 dL3'i. t'41.1.DYJ�i.1Gfi'i.LL tl
PLAN CRECK ME 101-01W-439»118 5103130
CONSTRUCTION Fid'! 101 -'000 -410 -£)+Mo $16100
M&Cl lMCIA1,, FRE-- POOL 101-000-421,400 921,100
&1 L9C°t`RIVAL aYZ?,, -.i W- L, 101 -00042.0-000 $45.00
P141t10111D410 R�.K - POOL 1:011.000.419-404 SAO
r.
�-UMUM10il XUD PLAN MW CK
NOV OR 2002
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
;BY
DATE
INAL D
IN E R
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 ,w
BLOCKWALL APPROVALS
Steel
I/ sloz;-�
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
W.. er Piping
Plumbing Final
Frumbing Top Out
Equipment Enclosure
;Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
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)
I
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F(CE epai
CITY -M UINTA
BUILDING SAFETY DEPT.
'APPROVED
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