0108-164 (RPL)LICENSED CONTRACTOR DECLARATION 9
1 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. to
License # Lic. Class Exp. Date
Date r'` t f> t Signature of Contractor
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 Policy No.
J (This section need not be completed if the permit valuation is for $100.00 or less).
(..,), 1 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 1provisions ofrSection 3700 of the Labor
Code, I shall fo hwith comply with those provisions. %
Date: ft>� Applicant
Weffnin 9 ""Failure to secure Workers' Com ensation co era9 a Is unlawful and
• ' P._
shall subject an employer to criminal,perialties and civil fines up to 00,000, 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 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,. 4fd State laws relating to the building
construction, and hereby authorize; represe.ntativ?s of this City to enter upon
the above-mentioned property,or Inspection purposes.
Signature (Owner/Agent) ,-L ',t,`0'1. t�' _� Datet•"7
_ BUILDING PERMIT. PERMIT#
DATE j VALUATION LOT 0108464 TRACT
JOB SITE
APN
ADDRESS
Ps
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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p im MOM C=A, 92260
(°760)340-9882 C' Vf 6420
USE OF PERMIT
POOL A3 fO.R MIA
PC10 4i,IA.. A A!°,M.Vf� XR1.91a SHALL BE. 3'S+t FLACK AT PMPIASTER
INSPECTI;' W. POOL RQGt4R;fe$W ENCLOSURE, NOT INC;AIDYLIt.
POOL .Ai?2DIOR SPA, I's
Pff,twW FEE'(MWA1ZY
PL&N L'HUX FEE 101-000.439-:318 $X1.61
C ONS'E PUCTIQW FEE 101-000-11918-000 $91.00
*FFICHANIC'AL NII -- POOL '101 -000-421. -000 82-410
F;I.YS•'"d'12I•f JAI, "R; — MYCII., 101-000-420-00 @4.Ot1
PF..I.9MAn4t'1 ME P00i
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,
16 All,
p,�G - PE�RWFF0 ME 14 OW
$229.65 •
QUIN?A '4
CIS INCE DEp?
RECEIPT
DATE,
BY
DATE FINALED
INSPECTO
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 - J
Vents
Fireplace P.L.
Grills
'
Fireplace T.O. !
Fans & Controls
Party Wall Insulation '
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath f
I
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
_
/,�•
Footings j" 1
Main Drain
`
Bond Beam 4 I
Approval to Cover
Equipment Location
ry !
Underground Electric
i
Underground Plbg. Test
Q `
Final 1
Gas Piping
tic
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 t
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole 1
Underground Conduft y
Rough Wiring ? _
Low Voltage Wiring a_
Fixtures f ., ...
Main Service I
Sub Panels
Exterior Receptacles ;
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) i