0104-277 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm un0g,penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing witl'i 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
C11�114 IRC MIX,!
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 ani 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.
,�_)- P'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 is1issued. My workers' compensation insurance carrier & policy no. are:
Cartier, Yt [t s Policy No.MAT 0164*
08
(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 thoseiprovisions.
Date: Applicant •r .i �. ' Zh
Warning: Failure to secure Workers' Compensation cc erage 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. nnn
IMPORTANT Application is heieby made to the Director of Building and to
for a permit subject to the conditions and restrictions set forth
application.
1. Each person upon whose behalf this application is made & each per at
whose request and for whose benefit work is performed under or pursu to
any permit issued as a result of this applicaton. agrees to, & shall, ind nify
& hold harmless the City of La Quinta, its officers, agents and empl ees.
2. Any permit issued as a result of this application becomes null and Did if
work is not commenced within 110 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 properly for inspection purposes.
Signature (Owner/Agent)" % Date,
BUILDING PERMIT PERMT#
r
DATE % . VALUATION LOT 0104-277 TRACT ti
JOB SITE
APN
ADDRESS C
OWNER
CONTRACTOR /DESIGNER /EN (NEER
1). V=RTDnrE�0 b±Nm
rALeVRray°V.T3 & 8PXq CMP MAN CU1.
P 0. ,3.0;x.1716
74725 JQNJ DFIVE, ff ME 4A.
LA. q,]W°!A CA. 92,253
PALM i UM11 'CA 92260
("!40)34+7-9t 00 M- Lit, 355
USE OF PERMIT
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CO3 ds'i`I; ucncm inn 101-000419-000 MIA
VOW'HAMCAL MTI . POOL 101-000-421'.000 $24.00
1r,&XX,'TPEC:AI,PLI E" — PCX0L 101 -000420-000 $45,00
P1:UMB1140 Me -•• POOL 1.41 -WO-411 ZI'100
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543735
1 AM PRE -PAID =l
CITY OF LA OUINTA
FINANCE DEPT WFAL 11MVIr M'S DATE Now
S437,55
RECEIP,
DATE
BY
DATE FINALED
INSPECTOR
)/
INSPECTION RECORD
OPERATION DATE I INSPECTOR OPERATION I DATE 11 INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Ducts
Slab Grade Return Air !!
Steel Combustion Air
-Roof Deck Exhaust Fans i
D.K. to Wrap F.A.U.
Framing Compressor [
Insulation Vents
Fireplace P.L. Grills t
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall I
Exterior Lath
Drywall - Int. Lath
I
Final r
Final
POOLS - SPAS I
BLOCKWA_ LL APPROVALS steel
Set Backs 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 /' _D G
Waste Lines 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: �oe- 6�
Final I
Utility Notice (Gas) i
ELECTRICAL APPROVALS '
I
Temp. Power Pole
Underground Conduit I
Rough Wiring
Low Voltage Wiring I
Fixtures .. [
Main Service f
Sub Panels
Exterior Receptacles I
G.F.I. `
Smoke Detectors
Temp. Use of Power
I
Final
Utility Notice (Perm)