0107-083 (RPL)TiLICENSED CONTRACTOR DECLARATION
I herE jj,ffirm under penalty of perjury that I am licensed under provisions of
Chapt iolcommencing with Section 7000) of Division 3 of the Business and
Profess als Code, and my License is in full force and effect.
Licen '# • u• Lic. Class Exp. Date
�•D"ate ,d •'��+ f Signature of Contractor 4'�� 'rf
OWNER -BUILDER D.EQLARATION
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 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.
JK)P 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 Policy No.
(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 with those provisions. g
,Date: �i'• 40 .: r€ APPlicant x rht?.rrr/9�'{ � 9 An
Warning: Failure to secure Workers' Compensation coverage Is unlawful and
shall subject an employer to crir�iinal penalties and civil fines up of $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 property for inspection purees.
,476
Signature (Owner/Agent)` /` �A Date"��'"
- ff
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01011-M TRACT
S10=131001
JOB SITE
APN
ADDRESS
40 AWN7DA J11A . ' ,..Z
— -
OW�FN`ER�
CONTRACTOR
iaCyti..yV :CSF,FyE,q: LlJi
g//DyEpSIIGNNiER�/nE,N tIN��E{ER
off"11..•�Yyd''A+S�/.�JJ:S"wPOINLS
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5 3` 840 .� 4,16+•RY7.d.e+.t`A o" . aLS2�� �
R O..Y9OX 1804 -
1r.&QKTAiR�'.+>1. CA 92253
;°>3�2-,m W.'fi.`iNGH CA 92263
(760)322-7'782 MV 6219
USE OF PERMIT
P1001...AAl1t'IXOR VA
_604.. ONI' 'Y" • ALA-4k4."eP!''s.PaIRM' ARS IMiJST TIF, IN Pi.,}'. CEAT PR.0 PLP., TEP
INS.fte- T ION - POO4 EQUIPMENT 0,218 "LOSM'1* NOT 1NC,l,U' RD
UST ATED C091' 9:17 CO•TlML;tCUC3N
1 iDa83 isw
1'i , N ro1^ ECK Al2 M.0 151
CUNSTALtCH,,014 FER 107-000-418-000 $117.00
N.-sCHIVNICAL, YKE, ..1%001•,4, 101 "900-421.00D $24.00
EUC"a`RIC,fiL ,` ZE — POOL 101-NO420-000 $0.00
'(41 DAPINO KIE •- -POO . 101.000-419.001 $$27.00
r
rl ... ,.i'.0 "....XC�.i�i A.C�.�%i.!'': �2.✓.�Y'kJ.�r�at�f �.ri3iL'��F.
-M ',RPS V103
aPa6�,��
Woo
IMS -PAID
I. rMur 111`1" RIS IRTE MONIV
J U L 10 2001
CITY OF LA OUINTA
BY.' !
• K
DATE FI A D
INSPECTOR
�, �� o t
„, IV
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Formi' & 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
Steel
Electric Bond
POOLS -SPAS
V
BLOCKWALL APPROVALS
Set Backs
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
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
r
Gas Test
Appliances
Final
COMMENTS:
7'(7
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power -
Final
Utility Notice (Perm)