9809-089 (RPL)LICENSED CONTRACTOR DECLARATION
'vx j'•.hereby affirm under penalty of perjury that I am licensed under provisions of
6hapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14
W Professionals Code, and my License is in full force and effect.
O M License #r Lic. Class Exp. Date
LU r 4 .431; B C i_i 12; 3 thy+i
oZ r- pate `�%I 1;:1 /1 Signature of Contractor
�Or�
J U C - OWNER -BUILDER DECLARATION
W UJ
r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
toY 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).
M () I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner 1
O N
IL Q WORKER'S COMPENSATION DECLARATION
C Q Er I hereby affirm under penalty of perjury one of the following declarations:
F- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U (X) I have and will maintain workers' compensation insurance, as required by
O QQ Section 3700 of the Labor Code, for the performance of the work for which this
rn F- permit is issued. My workers' compensation insurance carrier & policy no. are:
't Z Carrier Policy No.
Cb S'E rk'1'.ls FUND 1423'J2O
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
✓Date: /X117, rr ri` Applicant t �' .e._ � s� • j s%a' .�-,� •�
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 restrictlons 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 inspection purposes. /%
VSignature (Owner/Agent) t, _ '*-•° -� 9 Date �- 1-Z2 5i
PERMIT # CONTROL # 40
BUILDING PERMIT
9809.0819 9
DATE VALUATION $1.4,.300 0f3 LOT TRACT
/,,,_
ti3 0
JOB SITE
ADDRESS/ 78-955'
APN - ^
OWNER
CONTRACTOR/ DESIGNER ENGINEER
I 111a
iR 61_ivT11:"jRAM.R
i7RM CT PV104,S AND 'CiiWRUCii0
S-J59.C:.2�9.�fBE'R CP.O.
O'?s 1524
LA QUINTA CA 97.253
PALM DES1sRT CA 42261
568-490 013119 1215
USE OF PERMIT
IkA)L tiNID"iOR SPA
POOL & SPA ONLY. ALARMS ANIXOR BARIttUM iZEQ 7iR1.0 F OR
PRE -PLASTER JVSLIAIiL>"i'I.ON
001; rWx71CiK { iA 14,311-0.00 LS
EVf MATED COS Cir' CONS'.fRI!CT.10N
1413M.00
'}'CRI}UT FRX, SiM MAR Y
PLAN CHECK Ffl% 101-000.439-3113 5105.30
(110141S'r'Rt7GTK N FRI
it{:CMANI4'AL b`.P . -- F;OcOL 10)-000-421-000
FL.C,CTIUCAL FCE — POOL 1,01-000-420-000 SJS.Qt7
PLIAMINCI FEF -- pC3C . 101-000-419-000 527.00
fi
1:
E
1
o�
R.K_ J , , ( ONSTR' UdON AND PLAN CI EO
$301.10
LESS PR'Z-PAID PEES,
$0.00
NOU-12 1998 ?
TOTAL VI:'RNIf'f f':UES _01U ; NOW
5363.30
OF LA INTA
�1TY
RECEIPT
DATE
BYy
D INALED
INSPECTOR
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
OX 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
BLOC KWALL APPROVALS
steel _
Set Backs
Electric Bond C� g ' _
r /
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test Q_
Final
Gas Piping �Q^
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 > G
Gas Piping
Gas Test
Appliances
Final �d��,� ���
COMMENTS:
rte
"" /�'�ii►.%�,/1!1 �.Q ��"/" � Gv/l/L Q��(/�
Final
Utility Notice (Gas)
/
�yy
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)
a -1 . 01
ci
TY 0 P' c�..Ji;' N'l
BUILDING c5 i
cllc614.--P
ACCEPTED.F--%j..
SUBJECT TO INSTA" LL."A'. s li,35 1,%;'3 P E" PR
AND ALL APPLICABLE CODES
JJ 49) E?y
.19