0106-160 (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 Exp. Date
:94 6 5 C531� in �.t.. 1w i
Date° ' %' I 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).
( ) 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
ectlon 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.
STWPF FUND 1"090641
(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 3700 of the Labor
Code, I shall forthwith comply with those/provisions.
Date ' ,4 Applicant 4'�
Warning: Failure to secure Workers' Compensation coverage is unla l d
Shall subject an employer to criminal penalties and civil fines up to $100 0
addition to the cost of compensation, damages as provided for in Sectic r
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and S fet
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 pson at
whose request and for whose benefit work is performed under or pur ant to
any permit issued as a result of this applicaton agrees to, & shall, in emnl
& 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.
Signature (Owner/Agent) \, R. R. Dates' � ;> �
Tv V. •
,tLDING.-PERMIT;
DATE VALUATION LOT ��-y TRACT
rwn logy Womt.
JOB SITE APN
ADDRESS
53-960 AVF MRA 'PANWIT27,
OWNER CONTRACTOR/DESIGNER/EN (NEER
�. i' rEIK.L+1•AP •' �..JU4 POOLS
53.060 AM RAMtY2 M 43375 ,1NGrNDMON ST
U. QTMrA C& 922:53 MD10
Q60)347 -M9
USE OF PERMIT
h. .
POlJae'33to>t;..A3'.ARIIVISPULPIRiERS SkW,L HIP, IN PLACE Wr PR&PIa"+,S7` R
INS.PECTIOV4. Pool, EKNiMMT 99CUMIUF'.T'eNOT 1NCi.t,IDWIA
7
C,k 92202,
COIL 1151;
POOL A.HDIOR SPA 91000,00 "
a
xrx xT" con air coms"nayanw;
$�'i��'�`t�9.'�'FIER 9UMNARY
PLAN CHWK FRE 101 -OM439-31 6 "0.20
(MPdS'r;<rf.IC'rI01a FEE 101-000-418.000 $109.00
MECHANICAL nZ -- POOL 101.4300.421.000 471,00
E CTRICAL. PEE -, FOOL 101.000-4253-000
P1t1JMMO FRE -- P010!L 101-000-419-000 $27,00
_A D
JUN 1 3 2001
I j
CITY OF LA OUINTA
FINANCE DEPTT!C?N'=T.Ifnj.. 1T AID) p1jk).d•(M-W �
RECEIPT DATE' BY
$274,20
INSPECTOR -•
k
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE _T[
INSPECTOR
BUILDING APPROVALS
r
MECHANICAL APPROVALS
Set Backs
Underground Ducts 1
Forms & Footings
Ducts
Slab Grade
Return Air
Steel •
Combustion Air {
Roof Deck
Exhaust Fans }
O.K. to Wrap
F.A.U.
Framing
Compressor j
Insulation
Vents
Fireplace P.L.
Grills }
Fireplace T.O.
Fans & Controls +
Party Wall Insulation
Condensate Lines !
Party Wall Firewall
}
Exterior Lath
I
Drywall - Int. Lath -
f
r
(
Final }
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
steel
Electric Bond
Main Drain _ry
Bond Beam
Approval to Cover f!
Equipment Location [
Final
PLUMBING APPROVALS
Underground Electric
Underground Plbg. Test
Gas Piping �� }
Gas Test "
Electric Final i
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
r
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)