0112-047 (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 E,xx.. Date
gel
Date +"w 1 Signature of Contractor
OWNER -BUILDER DEAL/ARATION
I hereby affirm under penalty of perjury that/1;6m exempt from the COntFdctor'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 v!orkers' 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:
Cartier STATR FUND Policy No. 229.0411MI
(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, an 'agree that if I should become
subject to the workers' compensation provl ns o Section 37.00'of"'the Labor
Code, I shall forthwith comply with;those provlslon M!�
Date: ! ti -ghe Applicant—L
tr2s �.. { '-
r
Warning: Failure to secure Workers' Compensation'co'defage"is unlawf' 4�9rFrd
shall subject an employer to criminal penalties and civil fines up to $1,0(j;000, in
addition to the cost of compensation, damages as provided for in`Section 3706
of the Labor Code, interest ap d 'attorney's fees.
1•
IMPORTANT Application is hereby made to the Director of Building and�S'afefy
for a permit subject to the conditions and restrictions set forth /,6nis
application.
1. Each person upon whose behalf this application is made & each, erso at
whose request and for whose benefit work is performed under or pursua t to
any permit issued as a result of this applicaton agrees to, & shall, inderhnify
& 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 old if
work is not commenced within 180 days from date of issuance o ,such
permit, or cessation of work for 180 days will subject permit to cance Tion.
I certify that I have read this application and state that the above inform ttion is
correct. I agree to comply with all City; and Stap laws relating to the l uilding
construction, and hereby aut orize representatives of this City to entir upon
the above-mentioned proper.Vy for in"spection� epos@s. .. • Y' ti,
/Signature (Owner/Agent) %- /•n~� �` = -' "Date
P
BUILDING PERMIT PERMIT#
DATE Jl VALUATION LOT ' TRACT
_
JOB SITE
APN
AD.11 DRESS !8-715 SAGUARO 140AD
OWNER
CONTRACTOR/DESIGNER/EN (NEER
T, ^' rxa, Vranuiz: 's,114C.
VMM XES, WC.
78-120 CSE MADO tilC1it 204
78.120 CX211 Y ADO MME 204
L k. QEll�'t� IA CA 922S3
LA'Q73 N TA CA 92253,
(760)561-1866 claw 859, ,
USE OF PERMIT
PCXN, .., AMYOR SPA
,
P001„ AL&P.t4VbA"U S MAW. RZ XN PLACZ AT 1aMP1AS'1"1: R
WSPEC, r1OH, POO .l�, UIPPriENT 1t'l1CLOVI/URR NOT I'f+tt'.LUDMI . ,
POOL ANDIOR SPA 9,500,00 1.5
` • . .
:0;S'1CU"'T9D Mhff OF CONSMIJM10N
°9"'Al=L3 ou
PLAN i:3•D'a?WX F1:Z 101-000-439.318 mos
CONSTRUCTION FEE 101-ta, 0-41is-000 $1111.00
Idik:-HKkT1C AL FEE -- POOL 101.000-421.000 524:00
�PLEC 'WC.EAL FEE e a'C3OL 01-:00"7Z-000 QU1�.4!A
. ME! Mo FFIR . POOL 1,01.:000-419-00i1
DEC 13 2001
,
CITYOFLAQUI�i i,
FISNI'CS MPT
8ftW.-T0YAL C0WMRUCT101T AND PIAN C MCK
$299.65
IXU- S PRE -PAID
$0.00
t
s'
RECEIPT
DATE
BY AT IN ED
INSPECTOR
12 r; /r /
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Q
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
yo Q 9
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)