9902-001 (RPL)r 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 Licerise is in full force and effect.
License # Lic: Class Exp. Date
618892 C53i�
pate ' Signature of Contractor!, k-_�
OWNER -BUILDER DECLARATION , t
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 I I : - Policy No.
(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 .370 • of, he Labor
Cd`6e, shall forth :th comply with thos provisions. 6
;Dater Applicant 1" � / �
Warning: Failure Workers: Com ensation 'coverage is unlawful and
S hall subject ari 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:: t+
IMPORTANT' Application is hereby made to the Director ofBuilding 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 per on af-
- whose request and forwhose 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 authorize representatives f"this City to enter upon,
the above-mentioned proerty for inspection pur 6se.% �f
Signature (Owner/Agent) Y Date
BUILDINGPERMIT PERMITp
6D'U2-4)fl�
DATE -VALUATION LOT TRACT.
�l916,t.041. .
JOB;SITE? ..
ADDRESS �'.s53•.705 AVE -110A. Rk1BIO
APN I
- �-
OWNER
CONTRACTOR / DESIGNER / ENGINEER '
� to iiSr. AOiZ.i.!'rY.IV -
.t'�I..UE +�.AV A, POOI S
5Z�7* #kRi'r A.
2318 S. VI�IF�PtIi��'a AVEN�1�
CA
� ft ill; CA 52253
ON'lAt<IO CA 41761
(M)947-6474 CAL4 5740
USE OF PERMIT,
CSi3L. A i1�3. ,WOR ; 3'A
1.0011„ ONLY - NO 1TEA.M
PO4YL iV4D/0RSPA 14,M1,00 LS
. t
1,STIT 0 A aux; COST OF CONS 91 UC' ION
1. x,00,0 t
V E RNi1f .ti'EZ SUMMARY
PANG HECK.FEE 101-000-439-3ltt �t'lt,i5
q0N1q_T_Rj K-ITION FEE' -WRY-110-419-000 $171-M
'LIDWe fUCAL. a�t':�.-- F00L -.1.01-000-420-000, ' 54$.110
PI:UIt3B NO F.M POOL ,:101-000-41.9-000
4J(."MN ANnT,�3�r17.N�1��({,
_ �Q�(�s t
- y •• .. � �+r1^g
USS PPX-.af9lD LE S
$0.00
f0 AL PERMIT Ji'9r. ES DO NO'1V
$354.15
'FEB 01 1999
r El AQ 11
RECEIPT '"�,,
DATE 4 "
'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
POOLS - SPAS
steel
Set Backs +
Electric Bond2.1
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location _ Q
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 13
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)
CO MENTS: