0011-230 (RPL)LICENSED CONTRACTOR DECLARATION
(.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. ate
7
ate�� +"t ` Signature of Contra oct r+Kt 4 i
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of -perjury that I am exempt from the Contractor's
License Law for the following reason:.
( ), r.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).
O 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 haveand will maintain a certificate of•consent to self -insure for workers'
compensation, .as provided for by Section 3700,, of. the Labor Code, for the
pe orman.ce of the•work-for. which this permit is issued.
( 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 .STATESI�179D Policy No.; 22Sa•lIS1-i�►QA334
(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
wor ers' compensation laws' of California; -and\ag'r a that if I'should become
su� ect �o�t a workers' compensation prow SI,- s�of-Section 3700 of the, Labor
C,�de, I steal foFthwlth comply with tho ``��rov. s ons.
ate:4Applicanta��"
Warning: Failure to secure -Workers' Compensation coverage isounlawful 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.pe�son 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 becomestnull_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
constrpction, and hereby authorize rep;esentitives• of this City to'enter upon
the ove-mentioned property for Inspection purposes.
�
•-'"1 1�".'i :Dates1 1
Si nature (Owner/Agent).,
BUILDING PERMIT PERM T#
DATE VALUATION. LOT ��'"� TRACT
JOB SITE
APN
.ADDRESS
^ .r
OWNER'
CONTRACTOR / DESIGNER / ENGINEER
MW3°kX HOW
.E4t, O �l�`ON 62 VACAMON DOOM
3260 1'5'0. '
9522aMADVION ED
0248-604, . La1 43135
USE OF PERMIT
.POOL. Awwolt GmA
>r
PQOL A.vPA &3i+ti:1i..ALI1WSfi AkZR.1Ek''S SHALL 141E IN 111.k.CR AT
Pli%-PI.ASTER 11HOPWTIOR POOL WUIPMWT KNO1,08URaS IS XOT
PMCI..F3iYif;D IN THIS P10. MIT, 9'
PY.?L ANDIOR SPA 613
ESTMA;> 191 COST or, cONg.'rRCi'MON
&��i3(�13.tlli
wLr yke 8ummAwv
PL4N f"INKICY. FRE 10 1 -=-439-311 8 SI NUO
CONSTRUCTIO14 FEE 101•'000-6418-ClW 062100
MECHIANICAL FF -9 --POOL 101-000421-0001 $24.00
ELldICM,Y?,F,a. POOL, 101_0iX420_k10f)
PI,l3MB)I4E$ ix' ._ f'C�OI, `' : • I f5l � t9, 4a 3•IJCft9 3'X? f9�
IC
E71../Li'•,4�.�A.AL (aVSV0:9_SYi"ie�Lcb.{.4J'.1.�t AND l.':7.•A (MMIC
+ijJ141�. 1y.1
.
TOTAL TY.1'.RKn'F"Q9DtTN
NOW
-40
RECEIPT
DATEBY
DATE FINALED
INSPECTOR r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
11 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
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
d .
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)