0111-068 (RPL)r
LICENSED' CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
1-- 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.
O =) M License
+_#� �[ /�Lic. Class
7 �7 Exp. Date
r tY LU r— Cur,rl1J 4i 5. Ir.aZ A•-.ti.,�.r'�
Z r DateSignature of Contractor
to
J U C:) _ OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt,from the Contractor's
U) License Law for the following reason:
Z_ ( ) 1, 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
LO B&P.C. for this reason
N Date Signature of Owner
ON
0)
Q WORKER'S COMPENSATION DECLARATION
CL
C:, Z I hereby affirm under penalty of perjury one of the following declarations:
U-) � O () 1 have and will maintain c, certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
C0 Q () ( ) I have and will maintain workers' compensation insurance, as required by
O UQ Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no.' are:
qt Z Policy No.
00 5 Carrier S'1`.>q+.IM 1� )ND 10614W01-01
�0
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 fort with comply witfi'those-proviSions:
Applicant t
Date: �/1 .Y� r �..0 -- -k :
;
Warning: Failure to secure-Workers'•Com-p nsatron'coVeraage Is unlawful and
shall subject an employer to criminal penaltiesland 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•propertyQfor..inspection purpposes.
Signature (Owned.Agent)
Al BUILDING PERMIT PERMIT #
DATE VALUATION p LOT tD TRACT
I - � � t ' V �
JOB SITE 3l Q
ADDRESS
APN
OWNER VillCONTRACTOR/DESIGNER/EN
(NEER
V-00 C,`.i:,N71W, AVENUE SM 32 5
81963 WDZ3.MAM WEM'LME.
:£iIVF_ R, WF, CA 92506
I.oA QMTXA. CA 922.51
'
(16V)391-5300 CISLU 1889
USE OF PERMIT
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1:'eT.'.lnAY.L.Y-li• JI d".' SL SDyiT3
7P1.,A14 C14 10 ETA: 101-N043.9.318
0OT*7y't RUC:' ION FEE .101-00 0-419-000 $162.00
MEti;'}%AXIA:,ALWME•-POOL: $24,00
ULfYCTIZZICAL,.NILY,•.P001 : i011-000-420-000 1' 5.06.
F'L7M01:4015VE -- POOL 101-000-419-000 $27.00
NOV 1 4 2001
0E-•AQliiNT.,A
RMANCE DEpr.
. �•€3�r,='j,�ie!WCJ�'.s.l`•%�(fiC`l'lf?i;�" .�. :P1..A2�' C;�;;.�',� 4�
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01TAL 111111RIM, 117-E 914)) U1411 NOW
SANUO
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
���
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
4
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Pipgng
Plumbing Final
Plumbing , op Out
Equipment Enclosure
Shower P ns
O.K. for Finish Plaster
Sewer Lslral
Pool Cover
Sewer Connection
Encapsulation
x,23
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
6_ G
1 / v �,
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)