0011-171 (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
'Date + ' } Signature. of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat 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 properly, am excluslvely 'contracting with licensed
contractors to' construct the project (Sec. 7044, Business & Professionals
Code).
O 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'Cod, for the
performance of the work for which this permit is issued.'
I have and will maintain workers' compensation insurance, asr,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:
Carver Policy No.
STATE F"))
(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' compensationovisiof"is of Sec e_rW3700 of the Labor
Code, I shall.foithwith comply w,itti'those provisions! r '
No6ate: Applicant
Warning: Failure to secure Workers' Compensation coverage. is unlawful and
shall subject an employer to criminal-pe.nalties 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
fora permit subject to the conditions' and restrictions set forth'on his
..application.
1. Each person upon whose behalf this application -is made &jeach person at 1!;
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.inspectidn purposes. 4
ignature (Owner/Agent) 1 —'�`'�� Date
PERMIT#
' $ ;BUILDING PERMIT
DATE
C'.1,I VALUATION LOT. wri TJ TRACT
JOB SITE
APN
ADDRESS 7.8-715ROCKUKA -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Z�1•,[,�C,t') ISC IKEE
.4T 4, ,� DODS014 S:C.9MW°RLSMOIA INC.
.7 0 4115 ItCC',.MIR Y C"COURT
73011, C01'JN'9.`RY CIA. DR, DIR11'EF4
LA. O'UNEA CA 92251
1"'AAf..Ni CA, 92260
Q00;)346!4032. CBIJT 1044
USE OF PERMIT
POOL ANLJS1tUpA
..
,kE AI. u IVI PLACEAT PRE
1100L tt SPA
PLAISTRA 11N31'FXTION POOL EQUIPMENT KWILOSURE IS NOT INCLUDED
IN THIS PEI' MIT
11001,ANINOi 3PA 17,4:II,SiO "T,
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PLAN CHECI.KV& `ie1-000.439.31V SIV115
CONSTRUCTION'w1r tol-000-419-000 $4i8.ltfi
MECHANICAL FER -POOLS .. 101-0004,21.000
ELIM1..rRIC.AL,FRE.—I°OOL 1t19-_b>}Owf4?O-C4nCt-'if4S.00'
PI.tDi�4'�tINO FRF `- POOL, 1191-U00-41941001 M,60'
t SUB _T0`1' . COM YRUMWIT AND PLAN C".MCK
$59cas .
f 71�
$0.��00
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DL.r..191.d'[Y.
NVa�u"E�aS s .
NOV '2 8 2000 '
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RECEI(P�T F� ���
DATE{mBY
DTE IN L D
INSPECTOR
is
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
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall 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
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
t (�(01
ti
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
rTemp. Use of Power
,dinal
Utility Notice (Perm)
F