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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect..'���
License # Lic. Class, Z Exp,Date
43 110 kr[C
Da � ' r%^"� %Signature of:Contractor "'- f A -----
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) 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 ,x Policy No.
"I /PTATIBI FICIND M39015-90
This SEctlon need not be completed if the permit valuation is for $100.00 or less).
(�A-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'ofCalifor-na,,e d'agree)hat if I should become
subject to the workers' compensation provlslons>of Section 3700 of the Labor
Code, I shall forthwith comply-wlth h�se� 'rovisi6�riS. _.
Date: 4 . "'r�" 1.• 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 hiss,
application.r r,. #'
1. Each person upon whose behalf this application is made & each persornarl
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
correct. I agree to comply with all bityf;A State laws relating to the building
construction, and'hereby autho�rize%represef�itatives of this City to enter upon
the above-mentioned propert%/�4in"spection purposes. fp 1 may_
Signature(Owner/Ag r'� �-�� - Daterr!/�
F
PERMIT #
' BUILDING PERMIT.
-
DATE f n ; 1 VALUATION LOT (D �W'� TRACT
JOB SITE
ADDRESS
APN
OWNER �^
CONTRACTOR/DESIGNER/EN INEER
50.6185 t'`Y'PM13P011WE
1425x;. UIOMMYMRI ,
#.fs, QUCA. 92253
IM1030M, .AZ 65034
`
(60 )257.1656 , C:LU# 4990
USE OF PERMIT
5.'100L ANTIVOR BRA
P001, & SPA ONLY -AL ARNISMARR,t RMS SMALL HP; IN PLACE AT PRE
1F'LAS'fisR T.X8PF xC)K.P00L, QtDf.FMRN'T RNC1.OVURF 19 p3oT rN. C1,LlDE.D
ni `1'.HIS PERMIT.
FOOL AN:I7JOR SPS 10,t10d,#0.3 �
EMM FFIX. Ni l � Y,
PLAN CHRIC K FEE. '101.000 439.318 $1405
C OMS'i RUICTION FEF 101-000-418-000 $117,00
tddPCI`IANICIAL M& `- POOL 101 -OW -421-000 01.00
,t"f K"t',RICAL IMY, — POOL 101-000-4cCti000 $45.00
P 1ffJ'1UlY3INO FEE POOL 101.000-419-000 s .00
C034MC.iC°UOR t ' PLA.. CTK
$289.05
x. 4 PRE. -PAID IMI
(�.vv
A. : OCT 2 6 ZQQJ NOW
k
LA. QWW
RECEIPT
DATE "
eBY ! . i%f
DATE FINALED
INSPECTOR
v tr.• .'r t ,t tnyr^f R
INSPECTION RECORD
S OPERATION I DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final I I
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
OPERATION ' I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
POOLS - SPAS
Steel T(�
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric %� G!J
Final I I
PLUMBING APPROVALS
Gas Piping
Gas Test C
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 t _
Final
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wirit
Fixtures
Main Service
Sub Panels
Exterior Receptac
G. F.I
Smoke Detectors
Temp. Use of Pa
Notice
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FROM RJT_HOMES FAX NO. 7605646505 Oct. 23 2000 02:48PM P13 ,
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