0401-204 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
LU Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
r-_ CY u7
656128 C53.01 C�>3 !! � ��J10 idUa'
o
Z r- Date �2 {' # Signature of Contractor
CO O. C
r` C)
_J OWNER -BUILDER DECLARATION
U �
UJI w n I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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 B&P.C. for this reason
N Date Signature of Owner
ON
a Q WORKER'S COMPENSATION DECLARATION
oQ Cc I hereby affirm under penalty of perjury one of the following declarations:
FZ p () 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
O � Q performance of the work for which this permit is issued.
C0 Q L) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il F- permit is issued. My workers' compensation insurance carrier & policy no. are:
? z �-Carrier - Policy No.
ob STAT.1ai:'COMPrSNSAi1 046-6168-2011
Q (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 thosefprovisions�
Date: ? r"•C14 Applicant- 61'.
r
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 personi,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:
fi 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 up,ori
the above-mentioned property forinspection purposes. /4
Signature (Owner/Agent) Date !l -D
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT 0-401-M4 TRACT
S.17,000.00 17
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TRANS 1T+T.t?Zr RMSING INC;
CALIEVIORA P001 49 & S 'A.9 (FOXIM" CC
996V HOERTIVY MT1 102.
€6.100 A'dEE• TE, 54
SAN 1 I31 GO to 92131
COP.C`ML A CA 92236
(760)398.9222 CNA 00:11515
USE OF PERMIT
POOL A➢vTWOR. SPA
POO1dS.PA . AL.ARMSJ iARJUERS 'SHAL,L 81 IN PLACF AT NR&PLA5TE11
I1JSP�'1'i'U11. RQCfIP[u1d�,'l3T' F�[C`I.Ca;,1tiR1;'td0'I' [�FCL°T1LiFi3
PC54i,AND/aR SPAL
XVETMAIM-15 COST 01' Ct3NS.1.1.:t,C."170N.PIRWRTYROMIAT
3. a,i1G0oCtd3
WARY
.PLAN CHECK FEE 101.000.439-318 $117.0€1
CON;',P11.Uf",TION Z i011-000-418-000 $380.00
MEC RA2iICAL, FEE , POOL, 101.000.421.000 $24.00
ELXC'.FH)Cfi d, FEE -. P001,, 1011-000-420-000 *A3.00
Pl.t)MF2IVO ITE -POOL 101-000.419.000 $27,00
• y. r
-00Bi=AL, CONSTR UC:T ION AND T AN Cy;1�`�y1?/C�'Z
$3933,.00
yy��3�:
y����++pp��
TZ -1313 PRE -PAID IM
$0.00
R� . ..InIS11Q}I �' rDID9T OW
:$1393A1
:.�JAN00 2004
RECEIP""
° DAT -Eq WLJ111 erg
FI.q,1MCE QEP.T.,, 1
Y %
DATE FINALED
_ u
INSPECT
OR
yp
INSPECTION RECORD
OPERATION
DATE
I 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
steel
c -y
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
S?wer Connection
Encapsulation
Gas Piping
Lias Test
;appliances
r
Final
—
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)