0104-060 (RPL)�.r LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O 5 M License # Lic. Class Exp. Date
d yr
c Z N- r DatSignature of Contractor IL PIZ�^ P
EOWNER-BUILDER DECLARATION
W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) 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).
C")() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
OC\I
v4rELZ WORKER'S COMPENSATION DECLARATION
o Z I hereby affirm under penalty of perjury one of the following declarations:
U-) H O(,_.) 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J JQ performance of the work for which this permit is issued.
CD Q () (,) I have and will maintain workers' compensation insurance, as required by
O U Q '�SAtion 3700 of the Labor Code, for the performance of the work for which this
D: � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
ob a C%OM Pl^,141SATJ 046006168
J (This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I'shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
3subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with t o$ e pr sions r
Date: r Applicant �. d
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 ins ection purposes.
Signature (Owner/AgenDate
kyY
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0104.0050 TRACT
49 .p
JOB SITE APN
ADDRESS 79-4575 ,RA,!it.4 s
OWNER CONTRACTOR / DESIGNER / EN (NEER
23`I`t;tRYt CROWRU, C;OM'1rWID".8 ClAL1 VANIA F%0013 & vm CWP 1"A col
1535 00, 9y 3.M "I', "Till" 9200 14125, JO IKl DRNF, UC.TUE 0%
M Pr,I+'3:�N:4' RDII 0 CA 9'2.4018'' PALMA �d.tEWU !...A 92260
M (76())'.W-9000 C BW 355
USE OF PERMIT
POC?LAWWOR OMA.
POOT,f:IiPA. At.,l1RM.4/> A.;WZRS SNALL, HE IN PLiI.CLr.A1' PRA-P1_AX7 PP.
MOPECTION. 7.t.F, OF S' HIGH 1314CYfl1/A.1. I, CITY STANDARD,
POOLANIVORSPA
51T. 'WALL
21159-1.00 I's
11.00 KIF
LAN C rIECK :FU 101 -MV -439-318 $148.. 5
CONMICJCIFIOW 1"+'1:;11: 101-000-418-•i.' O $225.60
MksOKe' ICAI:e FEK _• Pool, 101-000-421-000 $24.00
31ZCTRJC'A1FRI0, -- POOL 101 -000-420-000 $4.1-00
Pi iI11f1E31WC'9 Ji>vY� POOL 101-000.419^000 $21.00
SUB -TOTAL CONMR.I3MI'CK AND PLM' ChF)C K
TOTAL MR.MIT VIM DVE.1150W
RECEIPT DATET f r kjF F BY IDA II�VA0 /0 1 INSPECTOR
2:l,6:1555'
$467.1041.5
$0,00
546725
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
Steel
Set Backs_ _ _
Footings
Electric Bond
Main Drain
_
_
Bond Beam _�( d%
Approval to Cover
r�
Equipment Location
_
Underground Electric
Final �j� j
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines
Electric Final
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
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)