0206-108 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000), Of Division 3 of the Business and
Professionals Code, and my License is in full''force and effect.
License # Lic. Class Exp. Date
Y Sr 128
C53 mc„-�I .5 /Z(
t"3
Date r Signature of Contractor - v� �`
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 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
Suction 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 STATE COMPENS:ATI ! Policy No. 04000610-0)
(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 p 'Misions of Section 370004 the Labor
Code;'I shall forthw' h
comply with thos�rov Bions.
Date: ! -Applicant p •. Q.}
Warning: Failure to secure Workers' Compensation coverage 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 persorrat
whose request and for whose benefit work is performed under or pursuantto
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 Cit ;.and State laws relating to the building
construction, and hereby authorize -:representatives of .this City to enter upon
the above-mentioned propert!, for tinspection
,pu poses.
Signature (Owne.—gent), � ` "�°` -°`" .v Date
"BUILDING PERMIT PERMITq
DATE VALUATION �y LOT TRACT
43
JOB SITE
ADDRESS 80-`409 SP"LSHZ'7�AY
APN
OWNER _ _ . _ = 1
CONTRACTOR/ DESIGNER/ EN (NEER
22 -SO W�`�3R Uig' C: Molal 9urm i 5'0
74 7 25 :ONI IMAM, a #A
CORONA_ OA 91720
:VALi -DM- `�'C CA 92260
(760)340.9000 t Blj dt)3r,5
USE OF PERMIT
POO?, AMIOR 2PA
POOL,, SPA, OAS AND IrLE+ZTRIC LII•iiE...S FOR FUTUR8 4180 (ANSI
2:•2143-1.995).Adfi?'t�:35F#.,�;C�17'L.i1`i
PPY,PL ^w�R' E111HSP 1014. EQU' IPWMT ENCLOSURE NO i' C1+ICI: UDE -0.
VALUATION W45000 I's
ELVd '.T. 3 dOS` OF CONSM JMON
h i ` saimmPadty
PUN CHECK FEE 1Calr000-439-318
i}`PISi'1tisCyT 3 99---I01=O CF4fgg o
MMIJAWICAL FEE— POOL 101»000421-000 S24 OD
I; ,ECTIRAC:AI. ME — POOL, 101.000-420.000 �'dlS.t?11
PLCIMBINO FEE •- POOL 101.000"419.060 MIA
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CITY®F LAQUINYA"
FINANCE®EPP
RECEIPT
DATE
BY
DATE RlAL
INSPE
T R
r1
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
POO
S - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
TT
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
Pool Cover
Encapsulation
/
Gas Piping
6
Gas Test
Appliances
Final
COMMENTS:
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)