9811-149 (RPL)z�" y LICENSED CONTRACTOR DECLARATION
ts.*
�oherebyaffirm Ander penalty of perjury that I am licensed under�provigions 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.'D'ate
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Co tractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with.wages as heir sole,,
compensation, will do the work, and the structure is not intended or ffered for -
compensation,
sale (Sec. 7044, Business & Professionals Code).
(�() '`l, as owner of the property, am exclusively contractingwith licensed.
contractors to construct the project (Sec. 7044, Business & Pro essionals
Code).
'am exem t under Section B&P.C. for this re�so .
Y� Signature of Owner 7 e
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.
( ) 1 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
(\,I I certify that in the performance of the work for which this permit is issued,
(?'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' compensatioin provisions of Section 3700 of the Labor
Code, I shall forthwith comply with'those provi ions.
,Date•, .: " 4 Applicant p
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.�agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
thabove-mentioned property Inspection purpose's.
e .
ySignature (Owner/Agent) r -art , _ Date /_�
f ; B:UILDING PERMIT PERMIT# �x
DATE VALUATION TRACT * 9 } t • ' '
xr LOT
S9.66s.00
•JOB'`SITE
ADDRESS 5 i4(1•AVVINI D.tA XWERI'l,
-
OWNER..
CONTRACTOR / DESIGNER / ENGINEER i
111ANA i.t TH'Y BJIE t..7t?
cWNERIBU1:1.DFR.
+> .3-7116 AVEN1.Dji RA1\1 RU,
' "LA'QUINTA CA. 9'!:53
t
�CAL4
41z
`
USE OF PERMIT
S'iUtUL �tNUi�al� Si'A
i
FOUL AND SPA ONLY - ALAR_k1SrBAlt%UUkS, SMALL RE Gni AT
PRE-PLAS'7'.R INSPFX f9ON. 1.0 Ur., N OA.RDEN WAU. ORCO
SYSTEM.
POOL AiNDIOI i SPA 7,500.00 LS
5 F i'. WALL 100.00 LF,
1111A'3Ti D COST OF COI NSTiz.UCTI N
9,665m,
PERMIT FEE
PLAN � ii.EtKK F'Kfi 1014)004314-24.19
,ION191V1.fArl?oNlFm 1tt1-C?(EO-4.18-000 g143.r
ELM-7TFU ALI'FE3--POOL 901-000-14120-000 S�l5.00
P.LLf14ISINO Fa -- PCK)L 101-wo-41", 00
f4W01ANICAL "-'E -- N(.'AJL 101 _0042I41w $24.00
Af
SI43-Rr;'.firr!0N AND ?I..AN CHFC K
I 3s
LIM PRE -PAID FF.17
%M
"DOTAL PCIM11T FEES DU IMOD
RECEIPT
DATE
BY j
DATE FINALED
5^
INSPECTOR
7"
;-v
INSPECTION RECORD
4 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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
1.el-0-11 AO
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
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)
COMMENTS:
(TSE �lL