0303-208 (RPL)LICENSED CONTRACTOR DECLARATION
affi
I hFeby rm'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.Ll
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D ch License # Lic. Class Exp. Date
flats a l i J! ✓ '? Cinnnfi irc of (.nnfrnrtnr
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 'k b 0 /0 W 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
(�yl 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:'- I`' '' Applicant 41Z
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
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 forinspectionpurposes. A
Signature (Owner/Agent) V/ lrl h.�- Date
. V o.
BUILDING PERMIT PERMIT#�2
DATE J VALUATION $1!5,O M LOT TRACT
_ 41Lj C,J
ADDRESS .49 490 �d�7CHO LAS Bdfi MPOI SASi JOB SITE
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
` TNI MCCUNE
l.)Vmn. - I3L'rlLDE%
,49-49011 .' MbLASNIARIPOVAU
LA.QULWA CA 92253
L .) CBV4
USE OF PERMIT
POOL AiTWOR, VA,
WUNYA- ALMW ^ d V,.XS NtLq" LF[' -1141 Ort-&t;K A.I t°RZ;P.L.A_S I LK
WSPECTION; EQCTIPIrgiz.W 9RCLOSURENOT YNCi,I DED,
POOL. NDIOR SPA ?S,CAO.a
EavMIAT'1�.C9 COU ori, C0Hv'r1..UC1r.' N
i
1.51000.00
PERWI, FA4F suhww4y,
PLA)q C- IEK FBF, 101.300-439.318 Sl4�,3D
.- CONS4RUCTION FEE 101-000-418-000 *153.00
MECHANT.CAL, WEE -- POOL -101-00421-000, 32r1100
1+:LXTR1CAL1P� , P,OOL. 101-000-420-000
I'I,at)MBINO'F'�. �a " POOL 101'000.419.000
r
M3B-;i0TfiJ.,COV .r.'UCTIE;WAND PLAN CHECK
A �. . LESS PRE -PAM FEES
$v.00
a3yw�r#R�T :�+��w NOW
.l4 a d .Ldcl�.lvld..1� +::i'+J:f? 1>10a NO 7►
Ml"
MAR .2 1.2003.
CITY OF LA QUINTA
FINANCE'.DEPT. :. .
RECEIPT DATE. /f� 1^� BX'' /'' �j DATE INALE INS.
tlr
1/ Ff v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Fo$ings
Main Drain Al
Bond Beam
Approval to Cover
Equipment Location /
Underground Eledric
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
TeImp. Power Pole
I.Inderground Conduit
h 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:
\. r
,�' • ycj-`/clo /nAkAa's' Y OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS PERMIT NUMBER,_ OWNER i%n% IM �l�in:� BUILQER �t1IAN M"Cd►J !
This form shall be posted on the Job with the Buf1ding Inspection Card at al tlptes�l'rt a consolcuous Wage. Only persons appearing on this list or their employees are eurAorized to work
on this -job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each aonlicable trade. all information raouagtad halow must ha camnlatad by annficant. Bon Rla° is not an arrantahla rwannnsta_
Trade 1 Creaeiticatiob •'
. r' ,• Contrai for :.. • - •• •-
- :.'..i' :: State Coritractos's LEeariBe . "'.. =.
Wmk9ts Coni rfiw losurorice .'
Cil 8usirress t1C'ense '
Company Name
Classification
(e.g. A. B. C-81
License Number
(xxxxxxl
Exp. Date
Ixxlxxlxxl
Carrier Name
19.9. State Fund, CalCompl
Policy Number
(Ramat Varies)
Exp. Date
(WU xxl
License Number
(xxxx)
Exp. Date
Ixxfxxlxxl
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