0106-306 (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,is in full force and effect.
License # % Lic. Class Exp. Date
bateZ f A1 Signature of Contractor ;a %rte •E r
" 'OWN ER=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
o 1 hereby affirm under penalty of perjury one of the following declarations:
LO O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
Q U {4.,) 1 have and will maintain workers' compensation insurance, as required by
O Q Secfion 3700 of the Labor Code, for the performance of the work for which this
LO
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code I shall forthwith comply with those provisions
P Y 1, P /
i..� Date�� Applicant__
Wang: Failure to secure Workers Compensation / overage is I and
Shall subject an employer to criminal penalties and civil fines up to POW, in
addition to the cost of compensation, damages as provided for in 706
of the Labor. Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of BuildinCdS ifetyi
for a permit subject to the conditions and restrictions set f rth or his -
application.
1. Each person upon whose behalf this application is made. & ea( h person at CI
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shalt7il luwl 111 lily
& 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 informati&'is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby auth r�ize representatives of this City to enter upon
the above-mentioned propert 'for Inspection urpos �
r
Signature (Owner/Ageht) �� Date
BUILDING PERMIT PERM T#
DATE pp ! LOT( J � '.65 TRACT
%VALUATION
JOB SITE
APN
ADDRESS
Y r,yt
9J7.- 41 Rli.�t'i T-10 LA. �JI1I NTA. X)RIVIF
—
OWNER
CONTRACTOR / DESIGNER / EN (NEER
T.D. S'}111.'IXER.TIN EVELt'7PMENT
CALGi 01MA POOL ; Vii. VMS (TO -P C01
PI (X:I= Off;' 1716
25 X -K, SAM, 301M, #A
rs..A QMiTIA CA !92253
PALM T."dWE T C,At1. 92260
(760)340.9000 C?BLO 355
USE OF PERMIT.
P001,.AN:C)/00 AND/00-SPA,
PO.OIJOPA,e`Aa F'.MSh%& ' ?I R.S SHA3:i1.,• BE IM 'P ..A%,it:.Pt d' PM:PLAS' EW., yy j'
iA;SlU'I"ION. 21 U. OF 3' H101.111LOC K `91A,b, CI Y ST.FAXI.A. RD,
' P0011.A'NWOR, SPA 23,00. DO IN's
5 Irr. WALL 25.00 LF
A.r•
,
i
UTMA71M COYTOFCQ.P]?slMMMOH;
w#,'K.:1as
PER WIT FAM RTAUMARY
PIAN :1Hn— FEE 101.000.419.318 $1,571-91
Cf3•NS`1'4d.C)c T10NF, 101-000-418-000 -000 U43.00
$III:;:SiAN1CAL ME -- POOL 101.000-•421.000 $24.00
F1,W IUCW, IfFE .. IRML `• 101-000-420-000 ` zoo
1'L UMBIHO'".9 •- POOL 101.000.419-000 U70
1
N 2 1 2001 ,
ry OF LA QUINTA
FINANCE DEPT tl IP,A )'1.`;f>`I, c0Jb' y'.i`.�i:TrM0Wt AP -f)3 PLANT CrfLEM
$+496).9 r
Imi i vm;g-pfim mv
$0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
pe
C_.
-b
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
Rof Deck
Exhaust Fans
O."o Wrap
F.A.U.
FrIming
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
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
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
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)