0402-036 (RPL)LICENSED CUNTRAC,+'OR 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
682901 B 12/11 r �t
Date ( j _ Signature of Contractor <
i -
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 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 'v'7'A9 : vUND Policy No. 229- 0019'73'7-2003
(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 3700o I ithe Labor
Code, I shall forthwith
' t comply with th%os_e•�provisions.
Date: )Applicant
t"
v
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 authorize representatives of this City to enter upon
the.above-mentioned property for inspection purposes. j
• i
Signature (Owner/Agent) t Date
Ir,
PERMIT#
BUILD_IN_ G PERMIT owl 2a%
`VALUATION
DATE LOT TRACT
— ✓ �- - f�—1tPt�.Qta
ADDRESS 5t-kt,"I.�D�i��i.1�IP914.>�Ei��0:. JOB SITE
APN _ N
,OWNER
CONTRACTOR / DESIGNER / ENGINEER
17I'OMAS }3UMN
DAVID I, ADDIS OT01`1
. ,0. BOX 134
41-780 MIAITACTF DR
L A QUINTA CA 9225?
BLIT"MA DiIIES CA 92201
t
(760)408--7526 CELO 3'714
USE OF PERMIT
P001:.AND/OR VA
POOL ONLY, ALARM 51RARRIERS SHALLBE 114 PLACE AT PIZF PLA~;TER.
INOPW,'1'10Y, BLOCK W.ALL,8,TQ1J1P&1rNT FMCM-SURE NC'YT )NCLUDED IN
THIS Plf:RMIT. 2001 CBC.
POOL AND/OR SPA 12,000,00 LS
MIM-AT'RI) COVr OF CC►F YTRIJC ON'
121000XV
PER. l 121 q07JRWA1 Y
PIAN CHECK FEE 101.000-439-318
CONSTRUCTION rFX 1.01-000-416-000
i7.F..0 TRIC.AL FEE -- POOL 101 -WO -420-000 O.42.0.000 50.00
PLUMBING FEF - POOL 101-000-4.19-000 $27.00
FEB 5 2004
CITY OF LA QUINTA
-
FINANCE DEPT.
S rL4-TOT•AL COMS1.RUCr1014 AWD PLAW CHS
IY3'.1'A1. PI—PRMrr FE, ES ME NOW
_ J
'RECEIPT
DATE f� (
BY
DAT INALED
INSP
_ �>
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
Sewer Lateral
Sewer Connection
Exterior Lath
Gas Piping
Drywall _ Int I ath
Gas Test
Final
BLOCKWALL APPROVALS
Set
Steel
Q*16]j&j1&1iW
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
Sewer Connection
Pool Cover _
Encapsulation O'
Gas Piping
Gas Test
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
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ONSTRUCTION
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