9608-077 (RPL)- -LICENSED CONTRACTOR DECLARATION— —i
Lhereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 ofAhe Business and
Professionals Code, and my License is in full force and effect!
License .# Lic._Class Exp. Date
t 31/�i
�} j1
Date Signature of Contractor af � f
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).
( ) 1, 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 work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 37QO0ltheLaP.pr Code, for the. performance of .the3woLkgforiwhich this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This section need not be completed if.the°pecmitrualul tion is for $100.00 or less).
() I certify that in the performance of the work four whic� 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 s o"uld become
subject to the jorkers o pensatlon provi` oostof Se°ton 7 0 of the Labor
Code, ith comply -with r isio �s. i
Date: Applicant � _
Warning: Failure to secure Workers"' Compensation coverkge' 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.
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 daysdwill subject permit to cancellation.
I certify that I have read this application and state that the above information is
cprrect. 41: agree-to,comply with all City, and State laws relating to the building
construction; and hereby- authorize epre ser%at;ues� of this City to ent r upon
the above -mention d propertyfor i pection purposes. ��
� rt
Signature (Owner/Agent tea' Date
BUILDING PERMIT
PERMT#
''�"�°�'
°°NTR°`" .
3 9 01
DATE KUM VALUATION $151,01" LOT
TRACT
JOB SITE _51-450 AW�NUM. UARkl5
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
y";�.IART PODELL
AMERICAN N P001., C0N �1'RU(7r10.N
51-450 AV1:;i'� IDA JUJX'KEZ. .
68573 &kX i;`EL1J?E :RD,
f..AQU1NTK CA. 92253
CN1'H1?1J12t11,MY
CA N234
C'61 #. 1101
USE OF PERMIT
P0(' l,.tkN0/1;112; SPA
POO), AND SPA MAN
P~: C 5;7' OF Ct3MSf'; t:T. t)Tr`
J.s�m".00
1;�1� K.R4i�' �k'�:13; Si)A9113�`�ii•S'
'I::f? 10.1
jrP�y,(tNC1C
{
Aji] lt,ft:,,tj�Mrj/'�,"�fv 1•"�,� 1��\�•difVi•`f1 ViYVy'
'101
d7�lljli•y�lV�
.--...-..�,�
/i}Yi
-l\'���7S�lYt�.I.ML Va-' "., PW_ 1, _ 00'0-y4'!'"M
$. A.00
rJXFd`',t R1C`A:L OX -- P001: 101.000-120-000
$45.00
rn
P1, ji1.1BING FEF - P9CX 1,(31-(204)419 4)tk?
$27.00
D M
CIO
C12
SUM-"!O'1A.T. CONIS'"i`RUGiMN A. ND PLAN CHECK.
$378.15
LESS
M -PMD VEES
$10,00
_.
TO ,IT1Zi11��'�' iy-F1r'S 1�fJ1:1 NOW �
,$379.15
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 - IM. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS -SPAS
Ale ZZI
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING 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
Pool Cover
Sewer Connection
Encapsulation
Q
Gas Piping
Gas Test
Appliances
Final
Q
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring .
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: