0001-108 (RPL)LICENSED CONTRACTOR DECLARATION
Cn I herebylffirm di.,Aer penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
License # Lic. Class / Exp. Date
W _Lo ai37i� `;.;4_. .� O +1201
cZti c
Date > �4 Signature of Contractor
O
UCD
OWNER -BUILDER DECLARATION r
W W r- I hereby affirm under penalty of perjury that I am exempt from the (o-ntractoes
~ d
N License Law for the following, reason:
Z ( ) 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
safe (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).
�
O I am exempt under Section. , BBP.C. for this reason_
O N Date Signature of Owner Y
arn
Q WORKER'S COMPENSATION DECLARATION
Q� I hereby affirm under penalty of perjury one of the following declarations:
F O () 1 have and will maintain a certificate of consent to self -insure for workers'
K Ld �= compensation, as provided for by Section 3700 of the Labor Code, for the
- Q performance of the work for which this permit is issued.
Q C) ( ) I have and will maintain workers' compensation insurance, as required by
jSection 3700 of the Labor Code, for the performance of the work for which this
U
L 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No.
Cb 5 tXa C, 1 1,tvi tv.r�cr+a!^1�
CY
g (This section need not be completed •rf:the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work fo which this permit is issued,
I shall not employ any person in any..manner s7a t 'become subject to the
workers' compensation laws of'Californiai, and g'ee that if. I. should become
3 subject to he workers' compensation provisions�6fi�S ction 3700 of t e,C96or
Code, sh II fo hwith comply with :those pr6visIF ' .. f
Date: ? APPIi 'irnt-... ; , j' ' i l -
Warning: Failure to secure orR&6'`Compensation cover a is unlawful and
shall subject an employer to criminal penalties and civil fine up to $100,000, in
addition to the cost of compensation, damages as provide r 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 asa result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Qulnta, 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 subject permit -to cancellation.
I certify that I have read this application'and stat that the,above information is
• correct. I agree to comply with all City, Ad St�"!e laws; relating to the building
construction, and hereby authorize representAtives of this City to enter upon
the above-mentioned property for inspectionu�poses: r
Signature. (Owner/Agent) (1_ (_ �`- t ate�____>_
PERMIT #
BUILDING PERMIT
4vi1t�-U0.i3�
DATE VALUATION ,i y(1l Qy Q1f3 LOT TRACT
JOB SITE
ADDRESS 49403 (:ASAti. DIG .. WO
OWNER
CONTRACTOR/DESIGNER / ENGINEER
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LAQ01-41A 4.1,l 92'15-+
PAL?vi 017SER:17 CA 9 15?-Wl
760", ,0-?SWX CIR1.8 1104
USE Or PERMIT
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TOTAL P°.+'itNlff rr AIN fD9 F NOW
RECEIPT
DATE
BY
DAM Z FI E
INSPECTOR
W
INSPECTI��N REC�R�
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANl CAL 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 Insulabon
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS o SPAS
! W
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
1:;0
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:
CITY OF LA QUINTA
.BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE By
EE OF $30
IV WE I%ppitoVED
Vilti. BE I sio 10B co mg. liol ON
.0"So Volt A SCHEDULED
JIAE Sin ,
M XV
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feeslew- (ppie-
31
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Q J�PNCTIDN BOX
> UO.T.
FROPERTY LK
UTILITY EASEMENT
El EC KNEL
BLOM
LIP
FENCE (HMHTTYPE)
GAS METER
varM LEVELER
AERATOR
-E--E- UNDERGFK)LM 91 ECO
.
19 WENCH MARK
REMM Y%LVE
HEAT.bi
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OVERHEAD ELEC
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OVERHEAD TELE.
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AREA DRAIN
DR. RETIA!
PVC DRAIN
-4
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00 PUMP
GAS GRILL
** CUP ANOM
SEE NOTES
NOTES:
AREA MAP
KEY MAP NO.
4�,1�5 A
rDrT
LIC: 5-18742
cm AF'
gAgrA
ADDR,'Lai- WW64+iwtJA5"
LAbUl-M+A EA
SCALE: r -a LOT- 8W)CK -SEC--t--
.TELE -W TELE, -
A AMERICAN
POOL
P OBOX 11996
DESERT.�A.
(760),322-6M
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