0101-263 (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 f ;-O Exp. Date
ADate Signature of Contractor
OWNER -BUILDER DECLAR' TION
I hereby affirm under penalty of perjury that I am e�mpt 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 & Prof essionals.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;
S& -tion 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.
0 T A T E P"il19V fM(f 2-00
(This section need not be completed if the permit valuation is for $100.00 or less).
- ( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner sg_as to become subject to the
workers' compensation laws of California, arrd"agree that if I should become
subject to theorkers' compensation 'p visions of Section 3700 of the Labor
Code, I shallo hwith comply with th15$-'etpt visions.
,gdtels '�• Applicant �.�f /.;Jlfi``I"
Waring: Failur to secure Workers" Compens tion coverage is unlawful and
shall subject an employer to criminal pe %alties 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 z
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, indemnity
& 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 C,,ityrand State laws relating to the building
construction, and hereby autnorlee representatives of this City to enter upon
the above-mentioned property for'• inspection purposes.
1 itr`
S gnature (Owner/Agent) } t `1, Date �' {
wp"r
-BUILDING PERMIT i PERMITtJ
DATE VALUATION LOT f]Pl� @1 TRACT '
JOB SITE
APN
ADDRESS
OWNER-
CONTRACTOR / DESIGNER / ENGINEER
DOT & NANCY EARLC
FAM.tti Y 1-10ou l~OMMU01170N
$„ Q3t`°ailtti3 ,t�� i�D?r3T��2�ci
53300AMMUDARdJ1N.T,�%�1'
1-4, Q191MA. CA 922:3
LA O1INTA. CA 92253
2893
USE OF PERMIT
1�i�C1$�.S'1'a4 3P3bwiifS LF. x. s' W'Rou(.fffll. nzU14 lrfnut'2.e.,m LF. X 5,
BLOCK WALL M, P? POOL XQ1:Y.1?%MENT. AIARN&P.t?s.(MERS` SH)__ "LL BE. 04
FOLA, :E, AT
POOLAWWOV. 10.1RA 21-91000,00 1-0
311°'!'. 'WALL,1.00 ',0
5 FT. WOOD FEt3C.1? 1?t3.Q41,1
COST OFComu$nom
hhyQp,�q}pp,q•{M&DWrl1;D
pp$RAV}}IDP Cf 4..1{'-T1"1;L4314C.7
KIM., C">t?1= PKE 101-000-439-2410 SIS2.10
WCH.041CAL ME .-1?t)OL 1411 of oo-421.000 124,00
PPd,t��i"".TRICtA.L.K9—POOL, 101-iW0--44r0-L'C.0 $-43.00
Ptt<ik1AR 140 FES - Pool, 101 .0 00-419-000 $21.00
0
is �q S, •y 1�S ry1�ypn� Tq♦t A 7-� .
S' ki L.9 '�d`G..� Ir�il.e E.: %Rtl�G46.�A.4td,�� r.'.ii .L� '�Lnt'eRV C.r.C,i4rJA-edL-
yrO a 10
JAN
RECEIPT
:DATEBy.
;
D INA D
IN
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs 6 O ?
Steel
Electric Bond
_
Footings
Main Drain
Bond Beam _ / ,0 c -
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
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
T
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)