0107-223 (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
Z Dater Signature of Contractor
r. r t
co
- - OWNER -BUILDER dECLARATI0N°� _
iI hereby affirm under penalty of perjury that I am exempt from the Contractor's", `
n License Law for the following reason:
Z ( ) 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).
C () I am exempt under Section , B&P.C. fc�rthis reason
N Date Signature of Owner
N
Q WORKER'S COMPENSATION DECLARATION
ZI hereby affirm under penalty of perjury one of. the following declarations:
p () 1 have and will maintain a certificate of consent to self -insure for workers''
3 compensation, as provided for by Section 3700 of the Labor Code, for the
Qperformance 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
D Z permit is issued. My workers' compensation insurance carrier & policy no. are:
CarverSy�+�Ap Policy No.
d SdadRECf:�MPRN�':t��'4 0400616S
J(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisio,P.
"`r
S Date: " r Applicant - r '
Warning: Failure to secure Worker C pensilon 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.
w.
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. f
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 F
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 t
'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 folinspec�>ion purposes
y► Signature (Owner/Agent) �'��� Dated
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �.� ���-� TRACT
JOB SITE
APN
ADDRESS79-1/0 p/w ,pyyy,�y��` LA yqINTA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TD D'."`d1Y,isCam'ALOtMAs3O%&SP
AJi"+?iMAN COT :
F'o 'wX rn 6
74725 JIDNI I.D TVF,, =rE qA,
LA Q:U3'T'A CIA 922,53
PQ,UNk OWERI" CA 92260
(760)340-9.000 L'BIr I :35:,
USE OF PERMIT
POOLANTWORSPA
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APPROACH DKIWYMA-If
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SWITIN tlCAL FIZZ .., POOL 101.000.421.000 �:lA,t34t
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RECEIPT
DATE * 1
BY `
DATE FINALED
INSPECTOR
r/�5f�/
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
_
Bond Beam
Approval to Cover
3
Equipment Location
Underground Electric
Underground Pibg. Test
Final I I
Gas Piping
Gas Test
PLUMBING APPROVALS
Waste Lines
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
�30/
rG
Gas Test
Appliances9"('—
Final
COMMENTS:
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)