0202-048 (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;L a=nse is in full force and effect.
License # Lic. Class Exp. Date c'
i
6,.38535 B Ric V?:t+'J02
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: 1
( ) 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).
O I am exempt under Section B&P.C. for this'.reason
Date o_. ,_ Signature of Owner kz: , -1 ; .s� ✓�
WORKER'S COMPENSATION DECLARA,TLONO
.1 hereby affirm under penalty of perjury one of the following declara ions:
() I have and will maintain a certificate of consent to self -insure for Iworkers'
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.
STATEKl"rJ13 228a2.4•00'W1
(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 sodas to become subject to the
workers' compensation laws of California, amend agree tha�j• if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant �=s
Warning: Failure to secure Worker's' Compefi"sation coverage isounlawful and
shall subject an employer to criminal penalties and civil fines up to $10;000, in
addition to the cost of compensation: damages as provided for in Section 3706
of the Labor Code, interesYand attorney's fees.
IMPORTANT Application,is hereby made to the DirectoJ of Building and Safety
for a permit subject to the conditions and restrictions set forth -on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a. result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this applicatiodand state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspec�tin�p�u,rposes.
Signature (Owner/Agent) ' = - Date-..
• / Tw
BUILDING PERMIT aFERMITk'
DATE VALUATION LOT 020'1-048 TRACT
/. 123
'JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
'PO BOX 450
�S») hE0 C�1,'tr'"��,SIAhT�U x9�'ii� 2U4
SAW Di1r00 CA,
1..F IQ.1 ? 'A CA 922 3
(760>564.1866 Cmc S59
USE OF PERMIT
POOL.A.'E`iWOR WA
. .
POOL.i t4b SPA ONLY. NO Fitf.A I-XI1. Al...0.52NISID A.Sdf2:iLP-S SHAH, HE IN ,
PL , -F>:IOR `fO P RFPi.,AST ER INSP11:CTIO14. POOL ZQUiPMENT
�".CLOSURL 146x' INCLUOET) YN 1'EAMM.
POOL ANi),'OR SPA 11,000.00 1,.5
��F'$I) f."OS OF (.Oi'i�"T.'.?Y.�' ON
�Y�j�pp'��p'� y'� �,'ry[ �V [�$g a •�ESTIM
dr Sild.`ifSS.Y. A .Ot dM' PMr�.C4A1VY6.5RY
FE
.. .
MAN C14,WK )�"ER 101-000-439.318 $81.90
CONSTRUC°r1cm FFF1 101-000.41 "00 $ 196.00
=
ELECTRICAL F72 •- POOT, 101.000.420.000 9 SS,60
FILUM8114t) ME .- POOL 101-000-419-000 $27.00
- 1 i, 1�1F Ud.:'t:ION JWD 1�i.a4Z+! r��?`L�,C.`,TC
11 LESS PTO -?-PRAM T A S1.'
. .
$0.00ALfJPEM'1'FLZS
DTJF, NOW
L.
$11179-90
IIA�UINTA -
RECEIPT GATE
BY;DAT
FINAJ-�°�
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.
Frarging
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
iz
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
EasTeslectric 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
( O Z.-
/Gas
GasPiping
Gas Test
Appliances
Final
a Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Final
COMMENTS: