0102-041 (RPL)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 Exp. Date
A6" Signature of Contractor i
r
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
n
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 mainta n 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.
S1U%T.9 FUND 046006.1,69-00
(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' compensatio provisions of Section 3700 of the Labor
"Code, I shall forthwith comply with se pr ov sio S9
Date:. 2Applicant
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 perseii atY
whose request and for whose benefit work is performed under or pursRA 20
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 herebytttorize representatives of this City to enter upon
the above-mentioned property for ins tion urposgs.
Signature (Owner/Agent %' - - Date2"
BUILDING PERMIT PERM'T# :
TRACT
DATE, J ; "'• VALUATION LOT TRACT
pp y��p ��t
a.
JOB`§ITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
e ,#>Iy1"{.AL )P,A IC 3 TOMMEW
C'AU&'t t'1,C.A1:f:A P001,21 & S A,S
41 OO MX' AR11M BUM A200
74725 JONT' D.RM,'0A
KEW.PCOr BEACH' CA, 112660
PAI Ae1. ESI IwRT CA 92260
(760)340-9000 BMX 5386
USE OF PERMIT
K101, AABWOR1. EWA
PI70L afa SPA C7NLY•ALARMS/8ARJUERS SNALL 8Z IN PLACE A9 PIS
PUNSTER I'I SP&MON. POOL Mt]WI+9.ENT Mp:.'iMM,13 NOT P14C';LIJliI?.It
IN THAS PER3++ IT
POOL ANDIOR. SPA 18,750.00 I's
E517YJVXKD COST OF CORPi'.�'UMON
96,750, 3
h':f~;M CRECK FES )01-000-439-338 10
C4)'AdE'I RUCTil.7N FUZ 10 1 -004 16-000
MECHANICAL FFY. -- POOL 101.000-Q 21-orlo $24.00
ELLOCTIvlt~;AL PEE - .Pool, 101-000.420d000 �I a:00
F'L,f,3t~n1T8!3 n1p... P06L, '101.000.419-000 'SAO
LA UU
KTL-1't_Y1L C'ON.EffVt3'G'l 10-1 !' :AM) PLAM C IT-WX
S422.70
LMS 7'.Ci &-PJ)JD FEES
f
$0.00
RECEIPT
DATE ,i t. /'':
BY;` L s� ...
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE I
INSPECTQR
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 Wali Firewall
{
Exterior Lath
{
Drywall - Int. Lath
!
{
{
Final
{
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
I
Set Backs
Electric Bond
!
Footings
Main Drain
f
Bond Beam
Approval to Cover
{
Equipment Location
{
Underground Electric
—/ �j r ►G
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
\ { 11
Waste Lines
Heater Final
{
Water Piping
Plumbing Final
E
Plumbing Top Out
Equipment Enclosure
E
Shower Pans
O.K. for Finish Plaster
{
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
l
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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