0206-126 (RPL)LICENSED CONTRACTORDECLARATION
= 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
656128 8"531.110 C-8 10131J%,,
/t
Date 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.
( ) 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 workers' compensation insurance carrier & policy no. are:.
Carrier 3T rE C10IMP'ENSATI Policy No. 04600.00163-01
(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 td 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 forthw'th comply with those provlslons,-IA
Dater Applicant 14— rte ✓✓ yJ
Warning: Failure to secure Workers' Compensafion 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
any permit issued as a result of this applicaton agrees to, & shall, indemt."n.
W
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and vo
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancellaI certify that I have read this application and state that the above informati
correct. I agree to comply with all City, and State laws relating to the buil
construction, and hereby authorize representatives of this. City to enter upon
the above-mentioned property for/'Fnspection�ppurposes.
Signature (Owner/Agent). - Awl fiW Date
0
B ILDING'PERMIT PERMIT#
DATE VALUATION page LOT 6 TRACT
m E
_
JOB SITE
x-60 D CRO O �. A QUINM DrdVX ,ADDRESS
ADDRESS
-
OWNER
CONTRACTOR/.DESIGNER/EN (NEER
IroDl:�I'dlr'�'oTDEVELOPIVA '1:
i:?t.T.:fMMAI''WLS &ff'.f S ,COP tAMI>✓O
PO BOX 1716
74125':CONI D0W, n-TrS+,#A
LA, QUNTA cA 9,2250'
PALM DTS.PIR ' CA 92260 .
USE OF PERMIT
POOL � VOR. 2a`.)•; A ..
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PLAN CNECK FER 101. 00-43.318 $122,95
CONSRRZIC'FION FEE 10111-0..004118-000 f:39.r3®
MECROUCAL FEE.. POOL '101-000421.000 $�l.
Psi FX,'TX1CAL I= — POOL 101 -PGO -420-000
PLUAiTM140 '94 --1Poot, 101-000-419-000 $27.00
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LEN; PL07,4MID FERS
91 40f.95-
$0,00
JUN -1 lUU1 'rQ AL PF
CITXOFLAQUINTA
FINANCE®EPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTO
am
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
— y
Set Backs
Electric Bond
-/
Footings
Main Drain
2
Bond Beam
Approval to Cover
- �S-
Equipment Location
Underground Electric
_
Underground Plbg. Test
Final
Gas Piping
_e
PLUMBING APPROVALS
Gas Test
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
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)
RAM S
SCIALE :PATE
PHONE
RAC PARCEL 21 FA&E
Ty
MAIL ADVF;?E!5S
RAM S
SCIALE :PATE