9904-226 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F• hapter 9 (commencing with Section 7000) of Division 3 of the Business and
Plbfessionals Code, and my License is in full force and effect
License # Lic. Class l Exp. Date
u58 it C53 11130%1Of
r
�Dat� Signature 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. 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. ♦ i1� 1�p
j �i�lZ.•1`at: B`l.��R-IJ���'2f1t•�1•Yi—:r<1
(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'rcompensation laws of California, and agree that if I should become
sub'ect to the workers' compensation provisions of Section 3700 of the Labor
Code, Ijs�htall forthwifh comply with,those provisions.
Date: ��
i tom.
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 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 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
correc`,I'agree to comply with all City; and State laws relating to the building
construction, and hereby authorze�epresentatives of this City to enter upon
the above-mentioned propertyffor ITy
c ion purposes.
"Signature (Owner/Agent) �' Dat
PERMIT #
BUILDING PERMIT "04-226
DATE VALUATION V��`�•� LOT TRACT
i= r, /9_1
JOB SITE I I
ADDRESS ` Ti�II Ct�Ii eL.E� Wt1X APN "
OWNER CONTRACTOR / DESIGNER / ENGINEER
NMI IDONN N*., .L3 FAMILY P0011,s i ONIKA1'.12.UC"1"Itr3;`J
78900 CA1312,ILLO C'4 iVY 53360 AVENIDA .ftANUREZ
I.A, C11JT.N'tA. CA 82253 LA t:,)I.JiI* TA. CA. 92253
r7�z#i15t3 -3si55 CaUt 2M3
USE OF PERMIT
1'Cit.5L r'i.N LilILR ► PA
POOL & SPAONLY.ALtllily S1BA12RJTlt8 811W.,.L BE IN 1'£,ACU A -T
PkL%I1LA1.+•0-A 1tVSPFAL3'10N.
P001. A'WXGR air#tri
1.i3,t)f34.00 11, i
Ui INIA".171 0 COST 01 Y CONNU,111?01.0N 23.ttaiN.011)
t'ERfAlIT FJF1 , S9hiAt.Ry
£"LAAN CHEICK M 101-000.439.318 $122,85
ftrrY101-MM-4,114-Wo,7`(y1
WKIIpIANIX141111
y1.t l.tHi)
f°J.�?3 "1�5 A4i Li l i"UVB+^`I ty L'Ul1! BnMl ��f)
171U,C11ZICA FEE ..P(M-N. 101-M-120-000 $45.tn1
PLUfut191I40 HE. —P0101, 1.01-0Uf)-419-000 S'J7.tr1'
S6_fE .T( '1�r �:.CJ.iv "t�2t1C"TI( ra AA?s �r.A'%i C;1 C ". ",Tg5LESS MU1.4"A10,11F, $0,00
TOTAL @31t:kt4tPiAT FEE'S 1)t1V, N0W 1 $407.8w
l�
I�,� EIPT't� tI�`t I DATE I BY / I DATE,FINALE 9 I INS/C�'`
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
—
Set Backs
Electric Bond
- l
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
15"
Appliances
Final
COMMENTS:
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)