9704-014 (BLCK)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
Prdfessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
/ate(rn
Signature of ntras r•
ti4
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 Policy No.
(This section need not be completed if the permit valuation is for $1.00.00 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 fSection -700 of:the Labor
Code, I,s hall forthwith comply with those p.ovlsions,
JDate: E' Applicant -
Warning: Failure to secu�Workers' Compensation coverage is lawful and
shall subject an employer to criminal penalties and civil fines up $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, indemnity
& 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 above-mentioned property for inspection -purposes.
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Signature (Owner/Agen`t) � � �� � ►`` - Date �!•'l^�^ � �'
BUILDINGPERMIT PERMIT# CONTROL#
4936
DATE v 31917 VALUATION il,227,3 � LOT TRACT
JOB SITE
ADDRESS 46-1110 .'ft.RtDtif?. r Tf, *V.AV
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
45160 i kIDGrET'M, WAY
P.O.13OX 835
T.AQU[N'TA. CA 922,53
F.ALN't Uh_S1N''(' CA 92,16 f:
l+5 f �)5feF3 4Q 2 4 { aLft 520
USE OF PERMIT
f3(.rfL1)1N
5 ELiP., 4' C3AitE-,EN Wrif f.. 19 LY., S' G111k1 ENI 14./•ALi..
SHAIA, I)E'PAIL KC 30851TE•' :f'OX
S .1''1'. WALL 19.00 L1"
4,r(, 11d.4T..L 51.00 L
�'Z�'�'.+1��.t�3�T;&� �.;C9e�".�' �3TI't<;Ot��``!'.Yd�2C�'�C:t;�
�.,�27.:3�.
�l �y•- Hg #, L�p 1a
C"ON-TrWICTION.i^fX, w j -ono-oh,-6w $31.1.10
i£'i'1t:7.AtJt1�.n+7 CT;1.€10
ECK
LESS PRE -PAID FE tS
KOO
TOTAL PERAVY FER-8 DUE NOW
APR o 3199,7
BY DATEu FINALE INSPECTOR
0
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
OX 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
BLOCKWALLAPPROVALS
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
PLUM BING'APPROVAI.6
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 Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
r
0SUNAIR
-POOLS
Pz
SINCE 1974
SUNAIR* POOLS
Swimming 9)'bol
Designers & Ouddlers
mow,
-X-,
P.O.BOX 835
PALM DESERT, CA 92261
Phone (619) 568-4014
STATE LICENSE C•53.397252
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CITY OF LA QUINTA
SUB -LIST
CONTRACTOR ADDRESS Pv ®. 83 67, PALS T/cSeF-T
OWNER � M JOB ADDRESS g5- I loo B21vGEq,:- UJAY
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous 121ace.
It is the responsibility of the General Contractor or the Owner/Builder to monitor the .sub -contractors that
are on this list are the same persons performing the work. Any changes to this list must be approved' -the
City of La Quinta Department of Building &. Safety UL& to work being performed by a changed sub-
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit.