9802-027 (RPL)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.
Licen£R #• ` Lic. Class Exp. Date
�61M_�Ignature
F3 = "" tt3i100
Date 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 runde�rs Section , B&P.0 for-this'rea"son--�"- - — '
Date ---/ _;O / a �" Signature of Own
y
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 Policy No.
GO.WEN RAGLF TNS. NW(A21$9200
(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 shallfforthwith, comply with thoseprovi�
Date: Z/ /i Applicant
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 null and void if
work is not commenced %lithin 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 prgpirty for inspection purposes.
Signature (Owner/Agent)
Date
BUILDINGPERMIT PERMIT# CONNTTROL#
DATE VALUATION LOT 9502.-027 TRACT 6571
S7.000.0/
JOB SITE
ADDRESS
APN
51-%0 AV[ANDA RUB10
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CORNON.EL CONSTRUC'I'[ON
CORONEL CONSTRUC110N
P.O� BOX 389
P.O.13ON 399
LA QUINTA CA 92253
LA QUINTA CA 92253
(760)564-4604 CU0 2261
USE OF PERMIT
DCC l
pool only
POUT. ANWOR SPA. 7.000.01 LS
ESTIMATED COSH' OF CONSTRUCHON
7.1lt21i.1111
PERMIT FEE SUMMARY
WCHAN1CAL FEE -- POOL 101-000-421-000
1:I-ECTRICAL FIS -- POOL 101-000420-000 $45.00
i'1.UNIHINU FRE -- P001, 101-000-419-000 527.00
I'll -AN CHECK. 61:.1.: 101-000-439-318 $58.50
CONSTRUC7I0NWE 101-0W-1118-000 $90.00
*ND -TOTAL CONS1'Cd 1JL- 10N AND PLAN CHECK
LESS PkE-PAID FEES
$2.1.4.50
S0.00
�199
a.
M�OTAL PERMIT FEES DUE, NOW
$241..0
j
RECEIPT
DATED/.
BY(/�/,/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forn?s & Footings
t
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
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Futures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
CORONEL CONSTRUCTION
P.O. BOX 389
LA QUINTA, CA 92253
4
t
951