0005-049 (RPL)U)
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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
Professional s_ Code, and my License is in full force and effect.
License # Lic `Class __) --Exp. Date
69064 5 ,,B M 06/30/2(
Date Signature?f Contractor `- - ^--- -
OWNER -BUILDER DECLARATION
I hereby affirm Linder 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
Section 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 INS. COMPANY Opp Policy No. Wll1 170041900
(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; i agree that -if I should become
subject to the workers' compensation provisions of Sectio 00 of the Labor
Code hall Z6rth ✓it�hApplicant
compl nwdh those. provisions,y� ,.
PP
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 ap
correct. I agree to comply with
construction, and611ereby auttb
the above-mentioned property.i
BUILDING PERMIT PERMIT#
DATE VALUATION LOTS TRACT
$1€i,EIU€100 S0 25389.3
JOB SITE APN
ADDRESS 78.914 DIUMMCA..1- DGF DRIVE � 7Ci9^��i1-
OWNER I CONTRACTOR / DESIGNER / EN (NEER
RJT M&ITiUM. � , NC.
14M Lr UJlMUTlY DRNr
ORATW, AZ 85 334
�a.
USE OF PERMIT
1425 L.'UN1V1WH`X'.1DR1.VB
MO = .AZ 85034
(502)257.1656 COLO 4990
POOL. & Stasi. • ALA 'RMSkBARF IMS SHALL .€3E IN PLAC,i? A'f
PERE-PIASUR INSPECTION �*
VALUATION
F-1r�'.�.,Ai11) COST OF Q:0I19MUCTTON
'PhMOr "M SUAMARY
Pwi awCK FRE 101.000-439.318
C014S!`RLtC:TION FKE 101-000-418-009 il7.00
MEC tWCAL FEE -- POOL 101.000-421-000 M00
ELECTRICAL 1T - POOL, 101-000-420-000 $45.00
PLUMt3i"90 RE POOL 1.01.000.419.000 S".60
and state that the above information is
and State laws relating to the building
-ese to atives of this City to enter upon
;tion purposes.
v 1^�/�/�^y� RECEIPT
Date !�
S! T(YTAL CONUMM-MOR AND PLM CHECY,
LIM )*)R9_PAiD MS
DATE
TMA -L. PXRMIP TIM HOW
DATE FINALED I INSPECTOR N
101000.00
$289.05
$0,00
$2859M5
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 — �2
Underground Plbg. Test
Final
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
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)