0106-171 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04
W Professionals Code, and my License is in full force and effect.
C C) License # Lic. Class Exp. Date
U
I; IX 656128 C,53 3TC"
ZO ti Date Signature of Contractor
J U OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a 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).
cr) () I am exempt under Section , B&RC. for this reason
0
N Date Signature of Owner
ON
O)
Z WORKER'S COMPENSATION DECLARATION
CL C Cc I hereby affirm under penalty of perjury one of the following declarations:
Lin O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w Y= compensation, as provided for by Section 3700 of the Labor Code, for the
mQ performance of the work for which this permit is issued.
Q U 'l(� ) I have and will maintain workers' compensation insurance, as required by
O U Q Spat�dri 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
O D° ,ATE C``0F&W3AT.1 ii+1f 11DYi1b
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 forthwith comply wit 4hose prov'sion
1 Date: �./ Applicant `� a'
Warning: Failure to secure Workers' Compensation eoverage is u ap [fety shall subject an employer to criminal penalties and civil fines up to 1
addition to the cost of compensation, damages as provided for in S Ion
of the Labor Code, interest and attorney's fees. 4
IMPORTANT Application is hereby made to the Director of Buildin and S
for a permit subject to the conditions and restrictions set f rth on
application.
1. Each person upon whose behalf this application is made & ealpersm 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.
/ i ,,,
Signature (Owner/Agent) k _ Dat
�
A
BUILDING PERMIT PERMIT#
DATE -"`/VALLOWON LOT 0106.471 TRACT
f
JOB SITE
APN
ADDRESS
X181 emus
OWNER
CONTRACTOR/DESIGNER/EN (NEER
3400 C'' WMMAl, AVENUE 01 TE 1315
74 7 2 5 JONI DRI 'U Q � UUM #AA
CA 92506
IYALM DROM CA -92260
(760)341 -9WO to 355
USE OF PERMIT
ITAQL Al AD;OR EPA
P001 -APP.. ALARM.%i1AIZA1'M,_' J SH AL,L 3.T IN PLACE AT PRE-PLASTI R
INSIPFECTION, 0 LY. RY T HIGN iBMM Pt-:,.E>..�NT WALL. CITY
^iLfl�i' 1-'•y. x)19"�' -j l�le:.Y�,i�r ,
WOOL ANIXOR SPA LZ
FRFUTtf TEF�'.'�s 9UM4ARY
PJAN 014=9 hIM 10D-000-439-318 $145,2:$
cowsZ".l,1.t emp.G w nz 101-000-410-000 $223.0
MECHANICAL 11RE -- POOL 101-1000-41211-001% $24,00
1YL1~:C:-1 R1C.°AL VEE, •- POOL 1011-000-420-000@�00.tiy20
,• � • we L 3,01-000-419-000 i9dI tifW
a oy
N. 2 1 2001
rY OF LA QUINTA ?� "
INANCEDEPT
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RECEIPT
DATEa
BY
DATE FINALED
INSPECTOR
•
/ j+ , r
INSPECTION RECORD
OPERATION
DATE
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
steel
POOLS - SPAS
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
ZNater Piping
Plumbing Final
Umbing Top Out
Equipment Enclosure
',Viower Pans
O.K. for Finish Plaster -
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
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:
`