0201-121 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty ofperjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
W Professionals Code, and my License is in full force°and a ect.
O =) M License # Lic. Class Exp. Date
IN
Z ADate I A I, Signature of Contractor " - .°-
Zo 0-
J �
OWNER -BUILDER DECL�ARATION
LU W ,
I hereby affirm under penalty of perjury that am exempt from the Contractor's
~ U) License Law for the following reason:
Z ( ) 1, 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).
Cf)() I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
O N
On
Q WORKER'S COMPENSATION DECLARATION
IL
C Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H 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
'r O J Q performance of the work for which this permit is issued.
m Q I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
00
0
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,
p. 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' compensationNpr visions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisio sJ! �f✓,
, - Date: � >r Applicant �� /_ f V I _�rti
Warning; Failure -to secure Workers' ,onsation coverage is unlawful and
shall subject an employer to criminal.nalties and civil fines up to $100,000, i
addition to the cost of compensation, damages as provided for in Section 3
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Saf
for a permit subject to, the conditions and restrictions set forth on
application. n
1. Each person upon whose behalf this application is made & each persoa
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.
y.
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 auth6rriie'representativesex,
phis City to enter upon
the above-mentioned property for inspec ion purpu
%Signature (Owner/Agent) Date
BUILDING PERMITS ..W PERMIT#
DATE ✓r VALUATION -jj /�qq LOT TRACT
JOB SITE
ADDRESS 455 31081.. 'r:.MST CMIX
APN
604-3102-01.3.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
X.A Q, iN A CA. 92253
.CI ID10 CA _92251
(760)2'75-6403 CSIA 1604
USE OF PERMIT
POOUSP..A.. ALARNISIBA4MERS SHALL BE IN PI-A.Ce A t' PR -F -PLASTER
IN'S'PFC3,'t0H, .PtaOI,�Q€1IP�i:N�
-FSTtMCOST OF COdWERUCICI3
,00
.
yEgMIT FRESWIR1
PIAN CHECK ITRE 101.000-4.3Y»318 5105,30
COWST,lttd0't'ION FHt'Z l o l w000_4 # f3_000 S162.00
W CKANIOAL ME •-POOL , 101-000-421-000 $21,00
ZLIMTRICAL, FEL? — POOL :: 101, -000-420-060, V:S.00
Py"um13•i1 a nx, -- 'Pool, 101-000-41 S�-0(30 $77,00
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RECEIPT
DATE
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BY/_,A,_A,... ^'"
BY
D T ALE
INSPr�, '-
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
steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
• y2- —-
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
7 — 71 5�
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)