0011-045 (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.
,.,License # Lic. Class Exp. Date
Dateo./ Signature of Contractor
AlfOWNER-BUILDER DECLAR .TION•
I hereby affirm under penalty of perjury trha I am exempt from the'Contractor's
License Law for the following reason: P I ' ' '•
( ) I, as owner of the property, o�'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).
as owner of the property, -am exclusively.contracting with lidthg6d
contractors, to construct the project (Seo-. 704.4, Business & Professionals
Code).
O I am exempt under Section B&P.C: for this reason '
Date Signature of Owner
WORKER'&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.STATE KIND
.
(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 khat if I should become
subject to the workers' compensation provisions of S cto�- 7}QJ;ofthe Labor
Code, I shall fo hwith comply with t60erpr vlsloh5. .
Date: • Applicant �r
Warning: Failure to secure Workers/Compensation coverage is unlawfulanii"
shall subject an employer to criminal penalties and civil fines up ,t9'<100,000, in
addition to the cost of compensation, damages as provided f r�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 .theconditions 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 t0
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, andiState laws relating to the building
Construction, and hereby authorize representatives of this City.to enter upon
the above-mentionedpropeFty forI�nspectl nrpupQ
es r r
r;
>Signature (Owner/Agent),>- :Date��
AJr
BUILDING PERMIT PERMITN
DATE VALUATION LOT (( TRACT
JOB SITE
APN
ADDRESS '
OWNER
CONTRACTOR/DESIGNER/ENGINEER
.l.,n7`fi:'lim Varnmn, mc. '
lat�3'i�. E11 VE° 8'1`Lil ES, ,14C.
1t -080 C-`AM1✓EUtA )0', MYV9, 204
78.080 CRUS WTAY10. OTi:t: E 2041
i,. C�iYil lrA CA 92253
LhQ`I:Ml' 'A. CA, 92W
-(760)564.1866. • CMA 859.
USE OF PERMIT
POOL AN /Rift E,i
POOL &SPA f:} ILY-ALAR?144.SYs1. RRIEl S SHAIX UK M-FLACIt AT YRk
P!",.ARXIt.;1NSPIECTTCiXV001. T?Qi HNNI•k?Y T MCLOO(JR9 19 140T INCLli.D90
INT HIS P PWIT
POOLANDIORSIPAl.4;3JD.04Iw.
P,
;irIM&M VEW NCTMM AIL'Y
my, 1 . ?11CA ,M, tI7 �-000, 421 "000 5.�K09
IS.0 C:'t'WCAL; EF, 101-00.6-4.:0-000
' PLUMBINGY� E 101-000. 1, 9.00U
P ,A14 =."kIRCK: INE 01 filfJ :1'J� 4 i d€ 94A5
COpsVFRUCTION FRE .101-000-419-000 MOP
3�3-°&"C "A r�3��I: ii�C''I'!2> Tl. PLAITf'::�I3�",tJ3�_.
�9�ai45.
I R3 IAF
RECEIPT
DATE) 1'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE j
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. 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
POOLS - SPAS
BLOCKWALL APPROVALS
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
COMMENTS:
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)