0110-039 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
C:) =) M License # Lic. Class Exp. Date
C3LLJ J 305 (11-531_11c 5n 1/03
f,f `" . � p'•, ` '
r` Z j Date' r�� 11 Signature of Contractor f `442'%''2A�a�
0 C)
o _ ._.._.—�—__•_
J U ^M •�---•---,•_,— OWNER -BUILDER DE'CLARATI'ON
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section , B&P.C. for this reason
LO
O N Date Signature of Owner
rn
d< WORKER'S COMPENSATION DECLARATION
p 2 Zcc I hereby affirm under penalty of perjury one of the following declarations:
F0 () 1 have and will maintain a certificate of consent to self -insure for workers'
7 LL
X W — compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
Q U „ I have and will maintain workers' compensation insurance, as required by
OSection 3700 of the Labor Code, for the performance of the work for which this
U
d v Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier ZMITH Policy No. 904603$01,
cb
J (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' compensation provisions of Section 3700 of the Labor
Code, I shall orthwith comply with•ttiose' rovisionS. /
Date i ., ��' r Applicant
Waming'Failure'tc 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 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, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property"for inspection
purposes.
Signature-.1.Date
BUILDING PERMIT PERMIT #
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DATE' !/ VALUATION •A-AYYq�s6W7 LOT TRACT
t A
-
JOB SITE Z' it
ADDRESS 44-725
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
3. NIOWIAL'1 t
08i3iiRNIS 111001✓ MAUITEK.ANCIZ
40-725 C'ALLE 3314 a t 1>AAE%P,4 A.
68.2005 :zM.Lk VWA ,
1A. QIJM1A CA !72233
C,r411fE.€3RM, C%.N G"A 9 223.4 ,
(76q)123-4510 (' BiA,
USE OF PERMIT
001:., A14DK)R I:r"FIA.
PO • ;SPA. fiL"'M:,?''DAMERS SKAf_L BE IN SPLA R AT P PLASTER
IN191"910 [1OK "l, OL L4UIPMEWE KHOLOSURK NOT WCi.EJDRD.
POOL, 73ND/CSR. SPA Att4ti+" La
P.Udt T M, SUMMARY
PLAN CHECK FL& 101.000.439.318
M1r BANICA1r FEE •- POOL. 101-000-47,11 -WO 524.6®
IL1:C.CTR.1CAL ,F13Z •- P?QL 101-OOD-4.20-000 �S.fTO
PIXYMOINO FER POOL 101-000-419-000 WWI
+ 1
� OCT 0 5 2001
CITY OF LA 01'111,A
FINAN-^- " ': _:'T.
SOB-`I.O7'iS& CI •s .... C11FO AAD_ I)LAN'CmIWYK
io4g3r7,5i
LESS 1yRF,-MDFE83
0,00
d?"!IIA-L 111aO ` PI 9S EIVIC A•CAW
S41.7.55
RECEIPT
DATE % f
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
T INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
[
Forms & Footings
Ducts
j
Slab Grade
Return Air
I
Steel
Combustion Air
{
Roof Deck
Exhaust Fans
[
O.K. to Wrap
F.A.U.
{
Framing
Compressor
t
Insulation
Vents
[
Fireplace P.L.
Grills
[
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
j
Party Wall Firewall
j
Exterior Lath
Drywall - Int. Lath
y
(
[
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
j
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
I
Shower Pans
O.K. for Finish Plaster
[
Sewer Lateral
Pool Cover
j
Sewer O'onnection
Encapsulation
Gas Pipfig
I
Gas Test
[
Appliances
[
Final
f
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring -
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Extc�or Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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Leo01 et-� --
q� L/00,000 e�« HTt
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w 44—
-TAN 0
1
FEE OF $301
it
NILL BE CHARGED IF THE APPROVED a2" 6�41 %
PLANS AND JOB CARD ARE
NOT
ON
THE SITE FOR A SC
INSPECTION.
NO EXCEPTIONS!
CITY CSF LA atiJINTA
W BUILDING & SAFETY DEPT.
�� _ �► APPROVED
1
FOR CONSTRUCTION
DATE19 S
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