0010-228 (RPL)LICENSED CONTRACTOR DECLARATION
1111,eby gffivm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
(V W Professionals Code, and my License is in full _ force ,and effect.
O =)M License # Lia Class Exp. Date
I-- a Ln 64
L�, 'JY p /�,t / wig ' / t
6 Z Date , �, '� /+'�:Signature,of Contracto , , moi/
r*- 1.� o-•. OWNER -BUILDER DECLARATION
JU co �� _..._. ,.....:...,_....
LU W ^ I hereby affirm under penalty -of. perjuryshat 1 am, exempt from the Contractor's
~ IZ License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as-fhei'r -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
L
N Date ' Signature of Owner.
O N -
CL Z WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn F- permit is issued. My workers' compensation insurance carrier & policy no. are:
-,t Z Carrier Policy No.
co 5 STATE PND 138:14640
C)
Q (This,�ection need not be completed if the permit valuation is for $100.00 or less).
_J ¢ �( l certify that in the performance of the work for which_ this permit is issued,
14611 611 not employ any person. in any manner so as to become subject to the
workers' compensation laws of California; and agree tl at if I should become
3 subject to the workers' compensation provlslons olSection 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 4" 11i. k/ 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.
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 of
any permit issued as a result of this applicaton agrees to, & shall, indemnify P
& 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 R
• correct. I agree to comply,with alVCity, andState laws relating to the building
construction, and hereby authorl�e representatives of this City to enter upon
the above-mentioned property for Inspectidpurposes.
Signature (Owner/Agent)`! Datef .
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BUILDING PERMIT PERMIT#
DATE/ LOT0014-2210 TRACT
/VALUATION
JOB SITE ! v
APN
ADDRESS
50-7&5 CYPRESS POINT
OWNER
CONTRACTOR/DESIGNER/EN (NEER
`3,° HOW-118 LIA111
aro BOX A10
14.2:5 . tJI'itlti=hi—TN-MVV-
L•,A QC1WA C.A. 922$3
MORWV., AZ 85034
(r,02)Z5.7nT r56 CUR 4990
I
USE OF PERMIT
POOL &S1aA 01141,Y -A OWb1S'i"SAP-, :CMS SiHALL BE IN PLACE, AX PRX
PLASTER #DgS!< ECT3C+1ai.POOL EQUIPMENT KNCI )URK 1.S )ITIOT iNCLr,5IDED
Y14 7'}YkS P2Lt2.MI -
P001, A1,1DIOR S1'A3 p c�01J,90 W,
X'STMADW COFf OF C:O1*iMMUC7t'If?.N
20.0-C 0'm
1134kq C""HWI X.., 101.000_4 9_$1 s
CC1VN` RUCT'147W RE 101 4300 419-00,1 911 .W
WCHIANICAL FEE •- ,Pool, 101-000-421-000 $24,00
K. ZC TRIC.A'L 3 9F, – POOL 101 -ON -420•1000 $45.00
PLIf Margo POOL 101-000-419-000 S2100
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'.1fflJB-!P01? cam.. CONTIRT,3Cl` (,W ANID :PS.111"3• MCK�2�#�.P9°1
+ UO3 PRP-PA!D'M
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$n_.00
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R R1G3�411 ..3 �Lv��aTOLS,fY SrS.fYdiL DUE lJ d, Y- YS
WA 65
®CT ,,2 6 2000_
all (I U LAQ�19
RECEIPT ,
DATE
BY i
DATE FINALED
INSPECTOR
4.~
V61-
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
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
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Final
Underground Plbg. Test
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:
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FAX NO. : 7605646505
Oct. 23 200
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