9909-134 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code_, and my License is in full force and effect.
O M License # �. Lic. Class Exp. ate
r W � 06 t 28 C KA W131l 2N
~ Z r- Date�� 4 ' Signature of Contractor
coo O � /
J U � OWNER -BUILDER DECLARATION
W WW r– I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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).
( ) 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
L
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
CL
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
U-) � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O UQ Section 3700 of 'the Labor Code, for the performance of the work for which this
d L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver Policy No.
Ob =)C. r a •rrf- MVINMIC, y a.(Pi I rK+Ad i re
J(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 becomessubject to the
workers' compensation laws of California, and agree thatAffl should become
3 subject to the workers' compensation provisions Of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions:
Date: Applicant
rte-
Warning: Failure to seeure W r eo k rs' 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 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 gbove information is
• correct. I agree to comply with all City, and State lasorelating to the building
construction, and hereby authorize representativeeof this City to enter upon
the above-mentioned property for insp�ra.p( poses:
Signature (Owner/Agent, �'"� Date
BUILDING PERMIT PERMITk
DATE owil _w "VALUATION gala, t.{I�i LOT TRACT
JOB SITE
ADDRESS9k-3i1M
AP N
- -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
t71L tONIN1114T ES,
INIC :lt,iOIZ:NTSA}";LS & SPAZE
5 PARK PLAZA, SUITE `1,30
/4•795 10M DRIVE, L
IRVINE' CA 9204
PAIM DESi W1* CA 922M
(760)'.440-90W f_Eli,fk 3"
USE OF PERMIT
KX)I. ANIS OR SPA
POOL AND &PA.U.KIN
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1,ai:(iYAr`'fft:,1L Ft' z -- POOL 1011-001)..r. 0
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I'LUMBIN! #t11114'001-- 1.0 14011-419400 �'�'1.Stl`1
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"77 71)
PRF -PAID F42ES
$ti..
TM*.ri.L i'EHti' IT FFY-S rtY!►1{•', NOW
$422.'70
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
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
ar/
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: