0109-232 (RPL)C14 W
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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
fi9(aS7'7 t; .moi 41
I
Date `' -' -- ' ' Signature of Contractor f+ 1 t
7--777
g. �.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractorr_e_
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&RC. 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.
( ) , f,have and will maintain workers' compensation insurance, as. required by
,.Soo-fion 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.
3TATZ F4:{i)
(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,
shall not employ any person in anymanner 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 s all'forthwith comply with thdse ovisions. ,
Date:' Applicant-
Failure
pplicant
Warnlr: Failure to secure Workers' Compensation coverage is un�a ul+and
Shall subject an employer to criminal penalties and civil fines up to $ 0 00, 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 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 authpri4? representatives of this City to enter upon
the above-mentioned property. orlinspection purposes.
Signature (OwneNAgent) ?� ti� r 4 '* Datel.4='f f"
BUILDING PERMIT PERMIT#
DATE VALUATION_ LOT 0109-M TRACT
f yo ` ♦
7 ' �.,
JOB SITE`
ADDRESS
APN
Ss- 71 (IMPIRRYURCY1115
?r;5-4-7a-02:�
OWNER
CONTRACTOR / DESIGNER / EN INEER
UTAHZ.;f2dfYls�LL CONS�fi?=.)�(.:"LION COR".
NA:1Tf3F Ai, EE%1'))XI'S
57-1.3915 1b.1411WK
7:3-9601 �Ii'(31✓:f'iNAY 1)
;Lm,x1f1V'.m, CA 92253
T.'AL-M*.DMR'i' CA, 92261D
(7m)5C,8-6726 t'f 'S i€ 52.20
USE OF PERMIT
F'001, A2MfOR SPP.
F'OOI,/&P 4, SK,, ANSIZB1•01 199:ti..A1..A 1tMSPfdAIW,,,1VRS .nKALI, S
t� 3�li�.A.C'�.A'i' 1�6i�...t?V::IbS'i'�1; 31J'13k�t?r�TiC1t>►
POOL AND1IOR SPA up IKS
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FL.V(1111 OKFEE. 101-000,439-3143 VJ11400
C[QNa7'IIt. CT100 FEE 101-(M-41.8-000 V96 00
�.N1*N;t' HA.1410-A 1. FKF '•• P001. 1011-000421-000 $200
f?,4.,ECTR.IC.AL W% •-' P-001, 101 -oho 32(1-000 $45119
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SEP 2 6 2001
CITY OF LA QUINTA
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RECEIPT
DATE_
BY
DATE INAL
INSFEC"
WA
JNSP CTJOH RECORD
OPERATION!
DATE
INSPECTOR.
OPERATION
DATE
INSPECTOR
BULDNG APPROVALS
RECHAMCAL 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
I 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
2LL03CKWALL 1 ApLPR-VALE
Steel
_
Set Backs —
Electric Bond
/l
ZZ
Footings
Main Drain_
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
(/
r?real
Gas Piping
Gas Test
-
Electric Final
_
Waste Lines
Heater Final
_
Water Piping
Plumbing Final
umbing Top_Ou4
Equipment Enclosure
Shower Pens
O.K. for Finish Plaster
wer Lateral
SAnr Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COM�fli C MTS:
Final
Utilitr Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F].
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)