0007-014 (RPL)U)
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. LICENSED CONTRACTOR DECLARATION
,I,hereby affirm under penalty of perjury that I am licensed under provisions of
hapter 9, (commencing with Section 7000) of Division 3 of the Business and
Professionals C40e, and my License is in full force and effect.
,License # + ` Lic. Class Exp. Date
441672 C33 Cha 06/30/1 c'
s
ate �'> 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):
O I am exempt under Section B&P.C. for this reason
Date :Signature of +Owner r
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. '
( .) 1'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:
Cartier SIATE FUND Policy No. 142361346
(This section need not be completed if the permit valuation is for $100.00 or less).
J. 1 certify that in the performance of the work for which this permit is issued,
I shalt 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
sub�.ect to the workers' compensation provisions of Section 3700 of the Labor
Cdde, I shall forthwith comply with those provisions.
Warning: Failure to secure Workers' Compensation coverage 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.
IMPORTANT Application is hereby made to the Director of Building and SAfety
for a permit subject to 'the conditions and restrictions set foi fi /his
application.
1. Each person upon whose behalf this application is made & each persd at
whose request and for whose benefit work is performed under or pursuE jt 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 voidif�
work is not commenced. within' 180 days from date of issuance of sucl5
permit, or cessation of work for 180 days will subject permit to cancellatiofi�
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 represe Datives of this City to enter upon
the above-mentioned property or inspection -urposes.
Signature (Owner/Agent) Date % e
7-7-00 BUILDING PERMIT PERMIT#
ON17.014
DATE VALUATION ���f•� LOT
TRACT
JOB SITE
ADDRESS 78. SA:ty TIM0,11y0 ,
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ORR
AFSTICCH T-M-.IA:H M
7 8-084 3 T O'= -
13600 VIA SAT.- i ESKIRT 110T SIPMC0
1d,A QUWTA a CA 92253
RANCHO O MMIXGE
CA,
92270
(7f)0)251.0350 '
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L4 4328. ,
USE OFPERMIT
POOL ApD OR SPA '
POOL &.SPAj ONLY- ALA TtNiWAR VERS SHALL SSP: IN-PLACl.+'. AT
F°RF,K.+ .STER DISPEC'i ION. TIM PRMIT DOES 1400 DICLUj319 BIA)CK
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WALL MR EQVI +T+4E N2 Li NCLOSU•M
V,F�%U Tlc7N 18100.00 Lo
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ES1<'.i MTED COU Off° CONSTRMITON
110,OMOD
FERAU 4." TMV SUMMi' RY
r%Q4 CHECK FEE 101.000.4394318 $122.85
CONS7'TraiJMON YEE 101-000.418-000 $SS9.00
MECHANICAL FEE— POO'L. l 01.000.421.000 $24.0* .
?,LECTR.I:CAL, FEE - POOL. 101-000-420-000 $45.00
PLUAf$ 140 FM •- POOL 101.000-419,000 $27.00
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$407.85
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TO T.ArJPh-RMr r, + $'S 33'TE NOW
$407Z5
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROYALS
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 8 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 APPR OVALS
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
Sewer Connection
Pool Cover
Encapsulation
_
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)