0160-169 (RPL)4
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. D��a��t»re
Date 1 : fSignature of Contractor 4 `•
OWN ER-BLIILDER•-DECL""AF 4TION'" j•� µw
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following 4eason: It..,:.
( ) 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 NA Professionals
Code).
14
( ) 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.
C),, 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 t3TI3TR FUND
Policy No. 10AM7 41i
(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 forthwith comply withoseprovisions.
Date: -' Applicant---
Warning Failure to secure Workers-CoMpens i I no erage issgFawful and
shall subject an employer to criminal penalties and civil�fines up to $100,000, in
addition to the cost of compensation, damages as', rovided 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 buil-ling
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propertyfor-insp,9ction purposes?
Signature (Owner/Agent'-- Date r�•� �t
BUILDING PERMIT PERMIT #,
1
DATE VALUATION LOT TRACT
JOB SITE d ..
APN� "
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
DATE PA.LM EITTEft� SPS
3400 CW TIR&1?iVEME !UITE 325
81965 MOV13TAM V.2EVv : AWR
RIVM- .,09 CJ.ri. 92SO6
LAt;;TlaAt"CA CA 92253
(760) 91.5:300 MA 1888
USE OF PERMIT
r
1,100L IsUDdC>R SPA.
POOLASPA. HE Di PLAC E.F'i T PRE-PLAS UR
1193P: T101k4. 3a00b E0T,1'tPii FN1 f E?IdCJ,OSiiR XOT fS4CJ.A1
P0.01, l+iN>!"}IOR 'SWA, I SPUD L8
RVIl naw COW M oinRMUC130M
3�V8 D.�149
PFAl ��:►'�:e+t�! RY
yyTi'Pr.t ((qy,���yyt"�E
/qy(4998 {p24
11K 111"? 101-000-439-318
V.0141S IZUC;'I'ION M, 101-000-418-000 $1.&9.00
MECHAVICA' TTY,-• POOT, 101.000-42,19.000 'S24.00
P-7�.(i�.C:rR(ICt.Al,tzEZ•!,[��.Rj�II&��1t)L 301-�1C�1}0-420-114010 S+k�1.jw
PL4AW.17:!1.l` O.PI. E.- P001, 01.
OCT 17 2001
CITY OF LA (2' HTA
xA pmur mw mu Now .:
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION ]77DATE
I
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 Wall Firewall ,
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
steel/O_3d-
Electric Bond
POOLS -SPAS,
O •
(�
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment location
Underground Electric=�
Underground Plbg. Test
j
IFinal
Gas Piping
_
PLUMBING APPROVALS
Gas Test
Electric Final
ttt
--'Naste 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
(l/
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)
COMMENTS:
l