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.LICENSED CONTRACTOR DECLARATION
%I hereby BY irm under penalty of perjury that I am licensed under provisions of
-4pter 9 (commencing with Section 7000) of Division 3 of the Business and
'P'r'6fessionals Code, and my License is in full force and effect.
Limnse # Lic. Class Exp. Date
,721005 C-31- 04!%120(
gnature of Co
,,Date Si
OWNER -BUILDER DECLARATION
I herehy affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner of the property, or my employees with wages as their sole
compensaVon, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of thq 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
Section 3700 of the Labor Code, for the performance of the work for which ihis
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier i Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(,NJ 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.bg�ome subject to the
wo rke rs,. compensation laws of Calif orni-a�2ancl agree"that if I should become
subject'to the workers' compensation provision�,of Section 3700 of the Labor
Code', I shall torthwith.c6mply wit� provisions' -1,
Xrate: 111-v/4-&'AAnIirtW 2
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 perfdrmed 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. 1, agree to comply with all City, and State'laws relating to the building
construction, and hereby authorizee-? Z
representatives of this City to enter upon
the a6ove-mentioned property forinsp!�Ctin purpos��
4
,Signature (Owner/Agent) ��ate4:::/
BUILDING
PERMIT#
PERMIT 9!H16424)
DATE VALUATION $2&0()0.4)0 LOT TRACT
lerl
� /4
JOB SITEI 1
ADDRESS 7&251) RIKKRALE'
APN
.,OWNER
CONTRACTOR / DESIGNER ENGINEER
NIA4 DUNILAP
I-
VALIC."YP00f. S1. �'IPA
79-230 WRKDALE
4741 C E. P MUM CAINYOW DR. 6 116
LA QUINFA.
CA, 92253
P ALM SI)RJN(;.S CA 92264
USE OF PERMIT
POOL ANDICA AA
V
z
POWSRAI�XrKf UR F GXWMFOUNP�JN - ALARXISIBAMERs MuST 6L w
POOL "UOR SPA
125.000.00 L'S.
-A13"w's, o
Pt, RMUT FRE WMMARY,
ALAN CWXX FEE
1,01-OW439-318 S1009
CONSTREYI-110,14 ME
10 1 -Mn- -418-000 V"15201
N,EGIA141CA1, IME — POU
101-000-421-000 $111-1,00
.C.LECTIMAL FU -- PWL
101-000-420-000 S45.60
PLUM1111140'FIX — PQOL
101-W-09AM $VAJ0
W113-TOTAI.,; CONFDRUCTION AND PLAN Of F.CK
A()
LESS VR241.Ad D FEE S
$000
UYTt% PERIMT FEEN VUE NOW
S51I.Wo
RECEIPT
DATE
By
DA E FINAL
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
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
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Ir i
Underground Plbg. Test
Final I I
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:
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