0103-223 (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 #,tt 9 Lic. Class Exp. Date 31/02
Date 3=.,-� Signature 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).
( ) 1, 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 SME M]� Policy No.
M}S�I.•A �Lb L"FJ L'C.J FI,C�Y�Y.I�-iJl
(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' compensatioH',provisions�of Section 3700 of the Labor
Code, I shall forthwith comply with those`provisions
Date: • . t_ p -4/Applicant—
ti, 4 /Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties%and civil fin'e's 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 & ea, i rson at G
whose request and for whose benefit work is performed underDIRd
any permit issued as a result of this applicaton agrees to, & s Eyee
& hold harmless the City of La Quinta, its officers, agents an mpl2. Any permit issued as a result of this application becomes n andwork is not commenced within 180 days from date of issu nce c
permit, or cessation of work for 180 days will subject permit t Icance
I certify that I have read this application and state that the above nformation isClFl
correct. I agree to comply with all City, and State laws relating t
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property,for inspection purposes.
Signature (Owner/Agent) +� ~`O-^� ` Date"_, lav;
F.
BUILDING PERMIT
DATE VALUATION LOTTRACT
22
JOB SITE APN
ADDRESS k+'^
Zt�i �.�A �P� ...
OWNER CONTRACTOR /DESIGNER / EN INEER
DAVID MILLM Ian 117C; 'rRPDF,8 C+L)N;i .LFCI ON
52.260 AVENMR AI IE v 1'l 19 S mmow
LAQUW-A:A CIA 92,253 S4 OkMANUD11, CA M-54
(-760)967.0069 CBLO 1955
USE OF PERMIT
A'A.
POOUNRA. ALAMSIDARRI90 SHALL, OF, IN PLACE AT P:I,'&PLAST.83L
INSPRCTION. POOL RQUIPURN T'MCLOSURE NOT MG=I UDE.D.
M000.10 L3
RISTMI A'Y.ii.Ib CM Or, CORMUCIXON
&°LM C1.3 XX PFI 101-000,439-318 $105.30
CONSTRUCTiON FLAT'" 101-i1MM" 19•-000 $16.3.00
MCHANIC AL FR .-POOL 101.000.421-000 i$24.00
Z1. fX;TR1C.. L BYES _- POOL. 101-000-4420-.000 $4100
Pb4T11T BNO FEM --- POOL, 101-000-419.000 92.7.0
3 0 2001
OF LA QUINTA
IANCE DEPT
00.99a'fttl:TC'I:'tON .M.M MAN CIMCK
LF33 PRE -PAW I''M'S
To ra FKMVM IMS DUE. YAG
RECEIPT I DATE/ :, .�r"I"BS"'' DATE FINALED INSPECTOR
ISIO. 100
V0.30
SO.0111
SIM
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs }
Underground Ducts
Forms & Footings }
Ducts
Slab Grade I
Return Air
Steel i
Combustion Air
Roof Deck i
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing ]
Compressor
Insulation ]
Vents
Fireplace P.L: J
Grills
Fireplace T.O. j
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall ]
Exterior Lath " i
Drywall - Int. Lath ]
G
1
}
Final
Final i
BLOCKWAL'L APPROVALS
Set Backs }
Steel
Electric Bond
POOLS - SPAS
_
Footings 4
Main Drain
Bond Beam )
Approval to Cover
i
Equipment Location
I
i
Underground Electric
Underground Plbg. Test/
—
6z
Final }
Gas Piping
PLUMBING APPROVALS
I
Gas Test
Electric Final
dso
Waste Lines • l
Heater Final
Water Piping }
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral ]
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping i
((
Gas Test I
Appliances
1
Final
�- Q
]
i
]
Final I
Utility Notice (Gas) 1
ELECTRICAL APPROVALS
Temp. Power Pole i
Underground Conduit
Rough Wiring }
Low Voltage Wiring ]
Fixtures
Main Service y
Sub Panels
Exterior Receptacles
G. F"i.
Smoke Detectors
Ternp. Use of Power
i
Final i
Utility Notice (Perm) }
COMMENTS: