0111-079 (RPL)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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
156'1e S C'`531 .0 f 1 3 t
Date 61-1 �� Signature of Contractor-
OWNER-BUILDER
ontractor
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
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 STATE ,�t?lA15�'1�UTJI Policy No. 04600 68
(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 37,90 of the Labor
Code, I shall forthwith comply with tae provisions., -7 8
Date: !' .. .oZX Applicant �!+* ` s o �o ". T
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.
',,,, T,-,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 bid 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.
'7
.FI `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 atiove-mentioned propert Pfbr inspection pur oses
If
Signature (Owner/Agent) r °'% �J. ^' Dat"'�
aZ� 7
BUILDING PERMIT. , PERMIT#
1110
DATE VALUATION
w R (�[y�7 {��p LOT 6,111"079 TRACT
r $2409M
Jftf,, C742J°Y,+.�15rP!'r{13.0
JOB SITE `'"
APN
ADDRESS 794 _070"'VVIOW
_
OWNER
CONTRACTOR/DESIGNER/EN INEER
PO X 1716
74725 J01411r►RiVE, 0.,�WIT; #€A
1�A 11"1M'A CA 92253
VALMDZUR.F CA
��j92260003
(760)340-9000 IN 55
USE OF PERMIT.
POOL SAI, ANVOI Mh
PK9WSPA..All—AW.M]AR'.��IERS 3110JAL 82 l.i�t � L e�#� lam`! 1�1'i�•!>N.��"I P�.�.°
1=`WLANUOR VA 24,009,00 LS'
Y
COST Off' C44 AFIR1�Q.""ITOR
gg�,�7 �'Js��`7j�y, �y�ipp{{ 'gg��/ '��,y ��f��E�S'J"P'..�1ll�ATIM
S.MWlk�,3Y-rIi4u�, Mi[Y.i./1�.[i.l
PLAN C,11MC ITS' 101.0007.4743-518 5191195
C'CN-S `PZtYCT.J9H ?VZF, 10-1-000-418-000 MAO
9WNICAL E. KM 101.000-421-000 $,24.00
,ft&CTJ•- PDO': 101-000-420-000 $45.00
,CAL ttPK
Fad�glaf 31lIcT 1r 1 •. Poot, ,;: yy 101.000.419.000
NOV 19 2001
CITY OF LMUMATAT, C.. 0141n�:�t�UCIR'Y9AM, PLM 0XIE K
FINANCEDEPT. LEBO PRE -PATDFEES,
$0.00
RECEIPT
DAT II ,!�
BY
DATE FINALED
INSPECT
/j
%
P."
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
i
Final
Final,.
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Electric Bond
Main Drain
Approval to Cover
(�
Bond Beam
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
,
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Shower Pans
Sewer Lateral
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
_
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
I
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.H.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)