0106-044 (BLCK)ILICENSED CONTRACTOR DECLARATION , ww
Chapter{9 (c encin ction,700U)'o ,Divis_ion3f,Business anted
Professionals Codesand my License Is in full force 'and '6*ffe
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6cCIWS l'iE P
�,Datej Signature C�actorZ,
—.—...�--7�-,.'.'i'."OWNER-BuiLF)ER DECLARATION,"
I hereby affirm under, penalty of perjury that I am exempt from the ontractor's
License Law for the foll6wing reason:
o"wn"er.of the pioperty, or employees with wages as their sole
compensation," will do the work; and the structure is not intended or offered for
sale (Sec .:JI044; I Busiin6ss & Profesilonals Code).
as owner of the 'properti,'am exclusively contracting with licensed
4 contracto . rs,to construct, the, project (Sec. 7044, Business ,& Professionals
Code)",
I am "exempt under Section I • B&P.C. for this reason
Date'
'Sign'I " of 0_w'n_e,r,
-
WORKER'S COMPENSATION DECLARATION
1,.hereby affirmI.under i penalty, of perjury,one of the following declarations:
ft"
have and maintain a certificate of consent to self -insure for workers'
,compensation,, as i provided for,by Section 3700 of the Labor Code, for the
II performance , , 6f'the .work for which this permit is issued.
maintain 'workers' compensation insurance, as required by
Sectioni 3700'6f, the Labbr Code, for the performance of the work for which this
rr I6eiIFiiifls"issued .Wy workers'' 6ompe'n's'ation insurance carrier & policy no. are:
Carrier F.', Policy No.
I��(This section need not be completed if the permit valuation is for $100.00 or less).
ypa Il certify that in thiiIperforrriariIEe of the work for which this permit is issued,
till not'employ,iny p6rso'n in any manner so as to become subject to the
4. workerscompensation'6ws of California, and agree that if I should become
,1subject to the work6r6' compensation provisions of Section. 3700 of the Labor
; Code1`6all forthwith comply with those -pro isions
Date t Applicant—
to secure Workers' Compensation coverage is unlawful and
�.-.Sliall subject an employer to criminal penalties and civil fines up to $100,000, in
to th'e"cost of compensation, damages as provided for in Section 3706
.-Tof the Labor Code, interest and attorney's fees.
"JIIVIPORf4NT4ppIication is hereby made to the Director of Building and Safety
,r'.
subject to the conditions and restrictions set forth on his
;iapplication.
,.V.1 !" . .., . I up,
1;- Each person on whose behalf this application is made & each person at
.,wlio's'e'request and for whose benefit work is performed under or pursuant to
I'vlany 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 "' Any pJr mit issued as a result of this application becomes null and void if
w n commenced within 180 days from date 'issuance of such
work is. not com of
permit, or cessation of work for 180 days will subject permit to cancellation.
:1 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 abova-mentioned propert for inspection purpo e
.'.Signatu're (Owner/Aaent) Date
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JOB SITE lj;ZVjg
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78- W icl VINA .I. �*,61 1". !"t
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OWNER ;' i,;
rami -V1911Wb-EV0,d.P.,WJ-dqT
CONTRACTOR DESIGNER EN61NEER,"'I
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""CALWO)UTTATOOLS
cap -P
ly 7 W95C 1. WOU
le 11
, I & SPAS
74-M ;0N1DR1VK',
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PX Af EY91111-0,12T CA 92260
-'ALM D.99M
1-90W !v
340
USE OF PERMIT
I' "W"A LI V STANDART) It, MR4,1
'Ilk
I
FIXEM7406 A0AV
VALUATION 1.9"
M
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V.5-MIATM) COST OF -CONSTIMC!11015
VErvif 9GA&MARY
PIAN CHECK FRE, )(1) _000-439.,xis
, �A,
�Xr,h
CMSTRUCTION FIVE 10 1 -000-4 18-000
PqXiCTR1CA1,FZV 101 -WO -420-000.
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PLIUMBINC11 MT, 1.01 -000-41 ID -006 qqj
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In.
JUN - 4 2001
FINANCE DEPT
fflj�� t"'.
Imu _P)RH4AW FEW
$7 1:
TMAY, TIARM.111 I(Mrs DUE NOW I!,
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71 25 v.
RECEIPT
DATE.
BY
INSPECTOR .Ip,',Jjjj,Itl, 015116-4-il
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR]
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs ?
Underground Ducts
Forms & Footings
Ducts
Slab Grade i
Return Air
Steel ?
Combustion Air
Roof Deck ?
Exhaust Fans
O.K. to Wrap i
F.A.U.
Framing ;
Compressor
Insulation I
Vents
Fireplace P.L. ?
Grills
Fireplace T.O. ?
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall t
Exterior Lath i
Drywall - Int. Lath )
I
1
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs I
Electric Bond
Footings i
Main Drain
Bond Beam
Approval to Cover
Equipment Location
f
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 1
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral i
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping ?
Gas Test
Appliances
Final
?
?
I
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit i
Rough Wiring
Low Voltage Wiring ?
Fixtures f
Main Service )
Sub Panels
Exterior Receptacles I
G.F.I. I
Smoke Detectors I
Temp. Use of Power 1 ,
f
Final ?
Utility Notice (Perm) 1
COMMENTS: