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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch6pter9 (commencing with Section 7000) of Division13 of the Business and
Professionals Code, and my License is in full force and effect.
License # . Lic. Class Exp. Date
15CSR
Date , <<,� Signature of Contrac
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
I hereby affirm under penalty of perjury one of the following dFeclarations:
() 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.
(s,.)•^'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:
Carrier'�r�kts Policy No. Ii�i3' Cllr,
r t..
(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 th workers' compensation p_rovzio,n�,s of Section 3 •d of the Labor
hose
Code, I sh fortM4 it comply with t'prov(sions:--
Date- ��_^ Applicant - C1--
- Warning: Failure to secure Work rs-Coriipensati "cover ge'Is unlawful and
shall subject an employer to criminalpenalties 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. .x'
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 ente upon
the above mentioneq property fo~I in pection purposes.% �,
G. dS _ ✓ i.
Signature
BUILDING PERMIT PERMI�TN�
DATEi �-
VALUATION LOT f TRACT
JOB SITE
APN
ADDRESS y�p•�c�
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1f3. ;�
MM -PALM IRIS..,
+ui•
tt����
:!'r00 CKff l AL, AVENUE ZrlS: 12`t1
,ERIEM
81965 .E+.riCiit91AN II�°Kv'� 1"R.
PIV.t+i li` -6 CA�l:a 106
x'. A QUINTA .•A 92253
(7c,)391-53 0 cT kLft 1 see
USE OF PERMIT
PC?a'9L,f:"sP A, A.4kAn''J!.S/E'lud,92) &P.3 SHALL- RZ, t?i PLACt AT PRZ-PIJ.VS'TK?R
J'NINNECA` 10-N. POOL XQUIPhA?A;1IT Ir'NClfOSUP"W NOT -INCIAII)ED,
POOL.aSNiJIOR SPA, 1&00n,00 La
4.r�f'iSA .��� i�.�rP.t C.11'.i:AO.L�i.•.KIL4ts�{
���IRA'lY.�
q[•��« �+1�' ,�Yy �ry�7 %�p�,(� „y �'.iatFf�dL7.FYl�.,3.LbxY'
R .�@��Y.A.,.i�+zY vRJr� CA �IJ�f.S.S°.tR.G1W4ti,L`
PLR:4O}ECK FE21 101-000439-.318 $103.30
..qQSyyRUCsH314 %o� 10I-00041:"000 *162.00
0
MVCHANIC AJ, Vre.E.- POOL . 101a000,421.000 924,00
L•LY,CTRIC.A.[,
OCA 17 2001
f CITY OF LA
ti ? i 1~aei .�IYJ;�•.t: �; addr`S�`6°di'.Yny'
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RECEIPT
DATEBY
e/,�j%
DATE FINALED
INSPECTOR
Y,
INSPECTION RECORD
OPERATION
DATE
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel f013Za— l ZZi
Set Backs
Electric Bond 1
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test _
Gas Piping J
PLUMBING APPROVALS
Gas Test l
Electric Final
Waste 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 _
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Ynderground Conduit
'r�,j _
hough Wiring
6.Z 66--e—
Low Voltage Wiring
Fixtures
�_ l �i . U -�
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)