0107-148 (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 Exp. Date
6)4611 rS3 ��' 03A 02C
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:
( ) 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 workJor 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:
STATV FLIM. •
(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 provis;?QR921_�e
of ction 3700 of the Labor
Code, I sha 'fortith comply with the a o,r'""
Date: ^r t` Applicant ,er�
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 forth on his
application. 11
1. Each personupon 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, indemnity
& 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 l 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 purpo's'.
Signature (Owner/Agent) Date''°
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0101-148 TRACT
".}fD eQ2SlA?�?
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
IJ !a£i d
MC.".Clv TRE k'001 -H VAS
QDFIL 0- AM) DIM11
PA DOX 1791
LA Quirm CA. 922,5l
LA C',,,uWTA C.A 922533
(ft*i()) fU•3585 t";1:i7.�'f i9ti_S
USE OF PERMIT
ty R
P001APA ONLY'. - AL.A,12P,3M&RRWR3 MUST BE [N PLACM AT
PRYIPLAS iER )HREC'T101•! - II00L. RWi.. ',: Ulitl WOT 0-1,UDED
a �:aMPLaANCF, WITH &U, FF.T) ;,RAI, & S"TAT.E DAVE% rtae°LULINCS THE
POOL AWMR WIA ;sCkol,ll.ib 1.13
E.WM : AM) C OS.r QF C:t3MfIR11B�]0bl'
30AW.00
PLAN O)MCK F94 SU4,93
CC, NSTRlIC,i10N PE's:' R-000 $ A4,50
MEC:k3.f4131t;`f1.'L IMF -- PfiOL 101.000.421..000 $24.00
P,14 TRICAL FM •• P001, IOlrf 00-420-t'WI %45.00
PUIMI4iNO PLS POOL $77.00
t�Al L.o ;
C l a R ARD 11T," C-ARCK
$.565.43
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
ILlfi1KCKNIB UE INre-
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
dr
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOL S - SPAS
SLOCNWALL, APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
FLUMUNG 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
Sewer Connection
Pool Cover
Encapsulation
z c7�
121k -
Gas Piping
Gas Test
Appliances
Final
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)
b�tc_IF
CITY OF LA QUINTA
BUILDING & SAFETY DEPT
APPROVED
FOF;FG TRUCTION
DATE BY
A RE-INSFE E 8F
INS
WILL I i rCF THE APP
PLANIS D B CARD ARE NOT ON
10 N
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