RPL (0108-110)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
690775 C53 C=1_01
gn
Date Siature of Contractor
OWN ER-BUILDER-DECLARATION'P f
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.
(,4 I have and will maintain workers' compensation insurance, as required by
S,06tion 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.
STAT FUND 1iltSS4 "fi 612
(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 tl a workers' compensation -provisions of Section 3700 of the Labor
Code -f -s I forthwi h comply with tho'se,provlsons.,-^�"
Date: 4 . �' %`- Applicant' � /' 1//• -
Warning: Failure.to secure Worker9" Compensatiioy:c6verage 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 tt,,e Labor Code, interest and attorney's fees.
4 '
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 purstianfs'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 authorjze-representatives of this City to enter upon
the above-mentioned property for inspection�p rposes. i
__Signature-(Owner/Agent)--- 01
- PERMIT#
/e 13/1,11.1 -DING PERMIT
DAT? / VA LOT TRACT
E
42
JOB SITE
APN
ADDRESS ¢ py,� �ss++vv wv�fpAvv
OWNER
CONTRACTOR / DESIGNER / EN (NEER
P.. C. HO BBS COW' Aff INC
DATER.A.M1"'1�'X EMPRIMS
1430 X � f -SA IMW Avg,
61965 MOUAIN VW9LA
ORANGE CA 92966
LA QUDaT'A CA =2153
('7611)391.5310 C'1:3IN 1888
USE OF PERMIT
PO- OLA -010 SPA
Pt OIJSP'.A,. MALAR VIVE BA °��..E23 S.i AU., THY IN PLACE XF ial'a,-PIAS EK'
111;i PECTIM. POOL FAWPMI F IT ENCV)SURE 110T INCLUDED.
Pf„OYos1k7+iWOIZ.:rPA 11,0G ,00 LZI
.��'�'�?� %TED C09M S?1n. COXX9- 11TCIC,' 10H
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7C-P..1C'S.67n rf �� E2 1W'4M. di�BA' AR 7:
F110 011 9. FEE 10.1i -000-x€39-318
?4KCHAV1CAi -FU — POOL 101-000.421-000
ZLECTRIC'AL FEE -A POOL 101-0W-420-000 SF45.OD
`#"UJ1MRrk10 "R,L o- POOL 101.000.419.000 112'�.r3ti
3YjB-T STA . ItTaTRUCTON AND VILM OIAWX
613.30
FRE-�'n1DYXI ;
$0.0016XA81
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l9eYih9n7 f�
AUG 14 2002
CITY OF LA QUINI'A
FINANCE DEPT.
RECEIPT
DATE, (
BY
DATE FINALED
INSPECTOR
5/,/
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
Set Backs
POOLS - SPAS
Steel
Electric Bond/
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Final
PLUMBING APPROVALS
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test's
Electric Final
/f
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
Gas Test
Appliances
Final
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: