0201-048 (RPL)Y. w
LICENSED CONTRACTOR DECLARATION
.'J 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/
7431 8 r,
i• ��" t�;�� Signature of Contracto
Date.r
OWNER -BUILDER DECLARATION _ t
I hereby affirm under penalty of perjury that 1 am exempt from the Contractor's
License Levi for the following reason:
( ) 1, 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).
O I am exempt under Section B&P.C: fo this reason i ! Ij
Date ct Signature of Owner
-WORKER'S COMPENSATION DECLARATION
I hereby' affirm'`. under penalty of perjury one of the following declarations:
(i) I Lave end;will maintain, a certificate of consent to self -insure for workers'
compensation;• as, provided for by Section 3700 of the Labor Code, for the
perforrnance. of the'work for which this permit is issued'
(f) 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
* per'mit is is* u .."My workers' compensation insurance carrier & policy no. are:.
;:Carrier Policy No.
STAT1114 FUND
(T6i's` 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 If�hould become
subject to the workers' compensation provisions of Se ti n 3700,of the Labor
Code, I shall forthwith comply with those�provisions. -
Date': :t.. S1 . Q 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 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 auth'orizeirepresentatives of this City to enter upon
the above mentioned property for Inspection purpooses.
i t t..✓ I V .1' j , n✓ i Date + •"!I (�
Signature (Owner/Agent) _ °
- ,:-,QPERMIT PERMIT#
DATE VALUATION LOT VfK+u:r�Y TRACT
JOB SITE
ADDRESS
APN
3- A'Tk1il'.PA RIM10
4 M
OWNER
CONTRACTOR/DESIGNER/EN &NEER
MIME, Up104A9. •
J .ryijiB�+F .l�9��L'td�.•ta?LAY .
IA QVWtA �,QA 122$9
19,010, ICA 92205
iAU ?`i'dt 11 , CW'13 � 4.998
USE OF PERMIT
POWSPA..ih4:A:iZl S18A.RRI'.MS SHALL St M PLACE -A7
��a•��r�.c;•r,c��, �s�?�. ����1��1" fay° 1„�r°i!.;���r�i� �r�}-�auc��:a�a�.r�,
�Jdti.Tailat'+.',t`t�� . • t �,9�t3,41 LS
NFA'ED C013f QF C0$h;'t7CI70X
1.21AN YVJ
y . �ARy }
PE1041E rim
PLAN CHWY, �'�' E - .I 101-000-439-318 $93.60
COPifi'Ckl.dCTIOki M- 2 101 4*0_ 418.000 $344.00
14Ft<'wku , not! 101.011?9 42e 1. •+l300 $214.00
U>.�fP,C'it$ CA'.1+23 - ?POOL. • 101,P00-•20-000 445.Otf
I'LbMaTP1d•;i?9!:G� . pool,, 101 « 00,•41 qV.0e,0 $A .ttti
JAN u 8 2002
t � w ;1U����C�`1�°.`szl ,.0 t 4.QR�i� �►5�1� ks1.-�#1�� �k�°C�T.�
� �:�:?,r5� `
LEND PRP,.PArD FaM
$0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
1NSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
U
Final
Underground Plbg. Test
Gas Piping
V A
PLUMBING APPROVALS
Gas Test
Electric Final
Haste Lines
Heater Final
�Jater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Enca ulation
Sewer Connection _
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)
�17J5G 011