0205-156 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of BUIL[�ING PERMIT
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE / rVALUATION LOT
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
690 415 B .TQC'.' A 0613W,(
fSate.Z; Ff l�. OASignature of Contractor, -
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 Sianature 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. !1
(y)r 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 FUND Policy No.
1$M06-01
(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' compensat"1bn provisions o1 Section 3700 of the Labor
Code, I shall forthwith comply with those provision r�
,r Date: t,1— 'LApplicant` ��o. �- �`. r �• yrs_' µ , �
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.
JOB SITE
ADDRESS 504 C AMMO
OWNER
PJT I RAMBa x:. f_1
.0BOx 810
LA. Q�TMA CA 9225*3
USE OF PERMIT
POOLANWOR SPA.
PC1;iiJS)? A11311Q, ALAMi! l
PRE -PLASTER, INSPRMION
NVI, Ali IWOR;S, FA
PERMIT # — �' .
TRACT
APN
CONTRACTOR/DESIGNER/
rarTUM07MI-15M., We''
14251>w UNYVTs'10-TYDRIVE
1a}.401NIX . AZ 35034
(602)257-165-6 M-4 4990
SYI.A)�L Etw IN VLA.0 Z'' .PRJOR TO
'1' (:I)W OF, CON S"IMIC1'10311
RAN MUCK PER 101.000.439.318 %105130
WNS5`,'RUC1104 FFMO 103-000-4.184)00 $16100
'14"W II NIf,A1.AMPOM 101-000-421-000 *24.00
ELL, C:°tRICA1,.FUX P001., 101-000-420-000 341.00
PLUMBINOPIKEPool, 101.000.41-000 6"140
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 I
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 iD
& 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:
$ r
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 prope for inspection purposes. °
RECEIPT
.Signature (Owner/Agent)'^ c , .�,.� Date
�w
SUS-jIM'Al- f_"O 11�7Rkf
PITON AND PLAN Miy=
U
1119W3
+. lrin3 1�q+y�wk'fi.
. (SAY 15 1111(12
CITY OF LAQUINTA
FINANCEDEPT.
DATE / ! 1' By
-a
i ssCli.1C).4K1
$363.30
$0.00
V01130
IRj
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
0. 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
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
- 02-
-Underground Plbg. Test
�, Z
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:
m
s -o:. ', moo` Pizv
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DA4ZI(2�12Y 57
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