0102-165 (RPL)LICENSED CONTRACTOR DECLARATION
I hef�iy7aifirm.under penalty of perjurythat 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 # r Lic. Class Exp. Date
351673 C5.3 q /al
Date'—�T Signature of Contractors - # "���
` 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 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 r1„ Policy No.
OND
OTAT229-00-0019334
(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' compen sation•provisions o�Section.3700 of the Labor
Code, 1 shal fo hwath comply with those provisions:, Y
Date:-hy, %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 attcrney'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. ®I(�
1. Each person upon whose behalf this application is made & each personP
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 for inspection,purpnose-s. �.
Signature (Owner/Agent) _ �< �� Date
rr.
BUILDING PERMIT -' PERMIT"
DATE VALUATION LOT {jjjeLi'�T_g�;4j TRACT
JOB SITE' L' / (� /
APN
ADDRESS
• 9-290 P.A.s"EQ DEL 10--ir
OWNER
CONTRACTOR/DESIGNER/ENGINEER
:rONM
HP+I.. HAW1701T dba VA.CAT.1019 SOOT—S'
79-290 PAMO DEL. Y
952,2 XU,
1A QWNTA CA 92243
LUCERNE 'i/A1..1 E OA 92336 `.
(;760)248-6045 (733LO. 43 4t
USE OF PERMIT
.1'001,./aM/ R. UPA
-
POOL -1S'P.P. At..Ala•.tISMARRUERS Frg07' WE, IN PIA_C ALT PR&PLAS;'I.R.
1P8SPI?t"..`a IOK 11001, lyQtl3lyM914T YtiCLOSURlK NOT INCf.i,)MC). 1.
F't'aa: L ANWOR. SPA. I g;Frf; 100 L5
E911MATF—D 4::i' ,Ff OF COAS �:3CITON
L �'7j� �►y�, �@�RR
.11Y MIT ADAM fY LIi�A C/Jd.LSt A
PLAN CHLECK FEE 101-000-439-31S S.105.30
C 0N,RTRtl0T1OW MOZ 101-000-41S-000 W2.00
MUCK—ANICAL FEN •- POOL, 101 -CW -421.000 $24,00
ELEC: t•R IC..A.L FLEE -A RzQ0. , 101 -0 0-42.0-M)0 �IS.R30
riaf,21•AadRl•?dar•,n, POOL— 101.000.419-000 $29,00
• Y
EB 26 2001
U e
9 713-1V AI:, C'C)WYrR:V.C':A.(0N AND PLAN 0MCX
$363.30
L.XISS I'1;i]?•1'./ D f MS
50.00
W
T'OT'AL :i➢:ERMIf FEES DUE' R'0W
r
RECEIPT `
D//ATE ,• :. (� ; t
BYJY+
DATE FINALED
INSPECTOR
\�i (• 1.7` l f
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings }
Ducts
Slab Grade i
Return Air
Steel i
Combustion Air
Roof Deck 1
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing ]
Compressor
Insulation +
Vents
Fireplace P.L. ]
Grills
Fireplace T.O. }
Fans & Controls
Party Wall Insulation -
Condensate Lines
Party Wali Firewall I
Exterior Lath i
Drywall - Int. Lath l
I
1
{
Final
Final I
POOLS - SPAS
BLOCKWALL APPROVALS -
steel
Set Backs
Electric Bond
Footings !
Main Drain
Bond Beam {
Approval to Cover
1
Equipment Location
I
Underground Electric
_
I
Underground Plbg. Test
- 1+
Final 1
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans I
OX for Finish Plaster
Sewer Lateral I
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping ;
P( (QcJTN
I5z
Gas Test I
-
Appliances 1
I
Final
I
COMMENTS:
i
Final }
Utility Notice (Gas)I
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures I ,
Main Service I
Sub Panels !
Exterior Receptacles
G.F.I. 1
Smoke Detectors 1
Temp. Use of Power
i
Final }
Utility Notice (Perm)