0402-060 (RPL){ LICENSED CONTRACTOR DECLARATION
1 -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 fornze and effect.
License # Lic.,Class,� Exp. Date 1 ,
54412 C53 H[C C-8 10,f 3 /d»
jai f " )�l Signature of Contractor
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.
`(,r4 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 oKkers, compensation insurance carrier & po i y no. are-
Carrier
re:
CarrierixE�s.Jia,t;„�taat Policy No. �4a'as o- Jo04
(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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those pr,.owsions.
Date: Applicant—
Warning:
pplicant 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
for' inspection purposes. f
Signature (Owner/Agent) ��!'� rDate .1
BUILDING PERMIT PERMITg ✓
-59
DATE VALUATION LOT it:_ V_ TRACT
...•,u
JOB SITE 115U-32.5 VKLU.%J,,J Y Flt" 11,400: APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN (NEER
SiTI<.A HOMM _ U='{.BIORRM, ROOLS $ SP -JAS (TOP :I'vSM CC
81.250 AVEE 62 85.3 001 NUU� E 54
L. Q1. WrA CA 92883 COAC;I-. F.L " CA 92236
(7co)-n5-9222 MX.. 00+355
USE OP
S 3C.�f,kN _1f01 ,,;PA
496WA.L GADS STUB IT OF 5° DLOCK WAL!, CITY 09';"I'DAf"I
AI_,1l.RUIVEARR.IERS SAH11. BE IN PL AC.f PRIOR TO PREPL.AS9`:cM
POOL ANDJORSO.A. 1,5
3 i�"I'.'iA►.!#L.i.. 1if.00 I�.i'
ES'9I A17D C OFF OF COkLrt9'ATUT(Mon
PIAN CHECX M E
101.000.439.318
$122,85
C:ON.TrrtUCTION PE,E
101-0011•418-000
;199.00
W4T.C1r3ANIC1\L FEE -- POOL
101.0001.421.000
$24.0
ELECTRICAL .Tq?E — POOL
101-0-00-49.0-000
$45,00
YGUMBING Milt __ POOL
FEB 0 9 2004
CITY OF LA QUINTA
FINANCE DEPT.
$117.{111
WJ13-TOTAL CC?1~ STFiJCC1:IOK AMMAN CIMCK
MW ]PRE -P 110'S
TO',rAL FF. [ ti= 17'EkS DUE If OW
RECEIPT DATES r / ', �`By I DATE ? JL D,/^ / (INSPECTOR
18,2S9so
$4f17.R3
X oo
S4076S
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I t
Underground Ducts
Forms & Footings I
Ducts
Slab Grade ! I
Return Air
Steel
Combustion Air
Roof Deck I (
Exhaust Fans
O.K to Wrap I I
F.A.U.
Framing ' I
Compressor
Insulation ', I
Vents
Fireplace P.L. I I
Grills
Fireplace T.O. i I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall i
Ext e' , r Lath I i
Drywall - Int. Lath 1 I
iI
1 I
Final
Final 11
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs ; I
Electric Bond
Footings It
Main Drain
Bond Beam i I
Approval to Cover
it
Equipment Location
I I
Underground Electric
f?
Underground Plbg. Test
Final it
Gas Piping
PLUMBING APPROVALS
3t
Gas Test
Electric Final
Waste Lines I;
Heater Final
Water Piping I;
Plumbing Final
Plumbing Top Out !
Equipment Enclosure
Shower Pans I I
O.K for Finish Plaster
Sewer Lateral ' Z
Pool Cover
Sewer Connection I t
Encapsulation G
Gas Piping I;
Gas Test
Appliances I
I
Final
'I
I I
'I
Final It
Utility Notice (Gas) l
ELECTRICAL
ELECTRICAL APPROVALS
Temp. Power Pole' I
Underground Conduit
lRough Wiring !!
Low Voltage Wiring
Fixtures fI
Main Service 11
Sub Panels 1I
Exterior Receptacles
G.F.I. i I
Smoke Detectors I I
Temp. Use of Power
I 1
iI
Final i
Utility Notice (Perm)
COMMENTS: