0207-164 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c'I W Professionals Code, and my License is in full force and effect.
M License # Lic. Class Exp. Date
I W f3. 535 .may B BITC 02128121
o ZO � ate ` - �� _gnature of Contracto[� ''
(p 0 9 1
J U OWNER -BUILDER DECLARATION"
aW r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the 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
sale (Sec. 7044, Business & Professionals Code).
( ) -1, as owner of the property, • am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O0
U Q 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 1 'CJ'; 1; TeUt 1y Policy No. 2202-0696x71
(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 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: '7 / fA,�plicants"1
Warning: Fure t
ailo secure Workers' CompeAsation coverage is unlawful and
shall subject an employer to criminal pena(ties)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.
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 property for inspection:.purposes. s
—Signature (Owner/Agent) '.�. � A�/ Date
PERMIT#
BUILDING PERMIT IV
0207-164.
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS '%> -21.4 -CAUX CAM
APN
— —
OWNER
CONTRACTOR / DESIGNER / EN INEER
.MJl,+ll AX. UNCH
ixxom war iw_,Q� TNC.
RID. BOX 450
78-120 CAUX =Tr`ADO M3]'.iE 204
LA WNTA OA 92253
LA QUITNTA CA 92233
(760)564.1866 C.Bldr, 859
USE OF PERMIT
POOLANWORIMN
PO(,IUSPA,.A,I,AIZMVB.A',I-P,IEP,S SIJUJ,.BE IN PLAM M10a TO
PRXP3. STEI:.14d5£'l i3'iION
k'OCJLA!NIORfSPA W
E611MM WWI Or 0O3ei MUC':1ION
20 OD
1" IT rim swhor,3L1.z'Y
FLAN (.'}WK FEE 101-000-439-318 $134.5S
t ONST UCT3014 VZE 101-000-418-000 VyZ00
MECI A.N10AL FRE -• PWL 101.000-421-000 $24.90
:h%ECTRICAI„ Fft - POOL 101-000-420-000 345.00
Ia'L�rSr3I1�6#. my .,,.. Klol.,. 101000-419.000 .,,. $27,00
2 4- 2002
CITY OF LAQUINTA
FINANCEDEPT.
M-TOTIS.T,d.0)= RUCTION AND PI..A l0.1;1-LeCK
RECEIPT .
DATE
BY
DATE FINALED
INSPECTOR
-1. Iee
/I
! I
INSPECTION RECORD
I
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR '
a
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs ,
Underground Ducts t
Forms 8 Footings
Ducts '
Slab Grade
Return Air
S
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Galls
Fireplace T.O.
Fans 8 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 ��%�
c
Underground Plbg. 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
or Receptacles
Sewer Lateral
Pool Cover
Temp. Use of Power
Sewer Connection
Encapsulation
Utility Notice (Perm)
Gas Piping
+
Gas Test
Appliances
Final Jr- • � . D 3 ��
1
1
it
t
COMMENTS:
_
r
�
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Nottage Wiring
Fixtures
Main Service
Sub Panels
Exteri
?
or Receptacles
G.F.I.
'. Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)