9512-063 (RPL)(n LICENSED CONTRACTOR DECLARATION
N 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r W Section 7000) of Division 3 of the Business and Professionals Code, and my
:'-�� �'ucense is in full force and effect.
r_ L n License # Lic. Class Exp. Date
Z Date Signatureof Contractor
H OWNER -BUILDER DECLARATION
J LU 1 hereby affirm that I am exempt from the Contractor's License Law for the
0- following reason:
Z ( ) 1, 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
saIVSec. 7044, Business & Professionals Code).
( I, as owner of the property, am exclusively contracting with licensed
contractorst construct the project (Sec. 7044, Business & Professionals Code). BP
( ) I am ex p under Section .C. 0 11Lc'Faso'�
. O Date t / Signature of Owner���
N
Orn
U WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
C) 2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
LO H O(r compensation, as provided for by Section 3700 of the Labor Code, for the
X W LL performance of the work for which this permit is issued.
Q J J ( ) I have and will maintain workers' compensation insurance, as required by
00 Q U Section 3700 of the Labor Code, for the performance of the work for which this
p U I permit is issued. My workers' compensation insurance carrier & policy no. are:
dLOH Carrier Policy No.
Z (This sestiori"need not be completed if the permit valuation is for $100.00 or less).
00 D
( %el'certify that in the performance of the work for which this permit is issued,
C7 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 should become
subject to a workers' compensation pr vision on
--should
of the Labor
I Code, I sh �o with comply with thos provi to
'' Date: 2 Applicant
/
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
4 1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State Il aw relating to the building
construction, and hereby authoriz6 representatives of thisl ' to enter upon the
- • above-mentioned property four i�ns�iecti n�'0���s�s. .,.
nature (Owner/Agent) l�" 4�ivw ��..�' Q Data
""'
-BUILDING PERMIT
PERMITaf0,12-063
DATE'
VALUATION S1�"LOT
TRACT
JOB SITE ADDRESS 44460 Ce11ii I NO LAVANDA
APN
OWNER
CONTRACTOR
ON+rn1EERMBU ILDER
NICHOLAS D &. ROBIN P0TEN7A
44060 CAMINO i.,AVANDA
LA QUIM.('A CA 92253
t. BLit
DESIGNER/ENGINEER
USE OF P"T OOL AND%OR SPA
PKI. AND SPA.
FEE DESCRIPTION
FEES
CONTRAOr AMO'UWr 15,(1G ,00 LS
E$TMXTE.D COST OI+` CONSTRRUCT ION
15,000.00
1t'uKmy-f IF rrs Summ;:ARY
P1,AN C,HFCI{.FE E 101-000439-318 $105.30
CONSTRUC'TO'R ME 101-000-41.8-000 $16200
NI CHNNICAL FkES -- POOL 101-0300421-000 S24A0
13-`LEc-" MICAL FFE -- POOL. 1.01-000-420-000 $45.00
PLUMBING FEF -- POOL 101.000.419-000 $�7.fiO3
` • SUB=,it),V'AL CONSTRUCTION AND PLAN CKECK
$363.30
aLESS PRE -PAID .FEES
$0.00
&AL !PE` VIrf FEES DUENOW
s1995
$363.30
'' DEC 2
184
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
f
OPERATION 7f77DATE
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 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
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:
I Z:
V4
ey
E
To Bic SELF-CLOSING
Al ATOS
LL
AND. -ELF -LATCHING.
UH
IL
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AND
DATE
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35-
IP
l_ 1 '1 Y V JrLH
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r Contractor /�5d/c--Qr�Address
Owndr /C,IV-D44S QMFIJ12_1,�- Job Address '7 �G� /•c�CJ,
DO
This form shall be posted on the job with the BuildingInspection Card at all times i
conspicuous place. .It is the responsibility of the General Contractor or the Owner/Buil
to monitor the sub -contractors that are on this list are the same persons performing
work. Any changes of this list must be approved by the City of La Quinta'Department
Building and Safety prior to work being performed by a changed sub -contractor. Failure
comply will result in a stoppage of work and/or the voidance of building permit.
TRADE
SUB -CONTRACTOR NAME
CONTRACTOR'S
LICENSE NO.
WORKMAN COMP.
NO. ON FILE
CITY BUSINESS
LICENSE NO.
GRADE/
EXCAVATE
a C
PIPELINES
FOU ATIONS
W v
CEMENT/WALKS
& DRIVES
ASPHALT
f
FRAMING
STEEL/
STRUCTURAL
O Ot?
MASONRY
PLUMBING.
CO
LATHING
DRYWALL
PLASTERING
Q9so 0i PJo
HVAC
ELECTRICAL
00
ROOFING
SHEET METAL
FLOORS
GLASS/
GLAZING
INSULATION
SEWAGE DISP-
PAINTING/
DECORATING
TILE
CABINETS/
INSTALLATION
ORNAMENTAL
METAL
FENCES/
BLOCK WALLS
_
LANDSCAPING
OTHERS
_�