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�� LICENSED CONTRACTOR DECLARATION
I hereby affix under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force=and effect.
License # Lic. Class Exp.. Date
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69(3`A 5I3 HLC A t?fa r3(7/2Z
Da _Zt-r2Signature ofrContract
i f
OWNER -BUILDER DECLARATION
I hereby affirm under 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
p rf rma cn a of the work for which this permit is issued.
jhave and will maintain workers' compensation insurance, as required by
,SPtion-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 OFT Policy No. WDE17,00411400
(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 asto�becdme subject to the
orkers' compensation laws of Califrnia, nd: agre
we that if I sKould become
subject to the workers' compensation provjsi ns of Section 3700 of the Labor
Code, I shall forthwith -comply withApb5se'p�ovision�
Date: s f"�/,— r''�Applicant
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 aove-mentioned property for inspecti°ompurposes.
`"'7" "�'
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S� ature (Owner/Agent)� Date
Lj. \L� VJ BUILDING PERMIT PERMIT#
DATE VALUATION LOTf� x TRACT
JOB SITE
APN
ADDRESS 79-959]3MC'JMNI iDO'E DWVE
OWNER
CONTRACTOR/DESIGNER/ENGINEER
R rr HOMM, INCA
RJT D -TI& 72v Mnn. ,199,
P.O. BOX 510
14 2 5 E UMV19491.T ill -.
L.A.QU1.WrA CA 12253
PHOYMM AL 550e34.
(602)257-1656 CBTA .4990
USE OF PERMIT
POOL AM/OR SPA
POOL &SPA ONLY- ALARM; BARRIERS SHALL BE IN PLACE AT
PRE -PL STER MPEC 1 ION
VAIMA T IOA1 I0,0>30.00 1A
RWATED COST OF C01NS".1+1' UCROR
10,0W.0€1
PLAN CHECK .FEE 101-000-439-318 M-05
CONSTRtIC i ION FEE 101-000-415-000 $117.00
MECHANICAL FEE --- POOL 101.000-421.000 $24.00
ELECTIUC,AL FEE -- POOL 101-000.4.20-000 $45.00
PLUMBING FRE -- POOL 101.000-419.000 $27.00
PLUMBING IEE •• SZWE'R 101-000-419-000 $30.0
ST. t13-xS7'3:AL CION a"rRTTC'.'n01TA9D PT.AW CTiEMIC
$319.05
LMS PRF _ PAID ;I+LW
$0.00
TOTAL YiMWf FIMS ;D'✓iT1^, NOW
$319.05
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RECEIPT
DATE (E ! /
DATE FINALED
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
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test fd-v
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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