0109-080 (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
C53 lucc-,g I ori 1/71C
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) . 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).'
() I am exempt under Section B&P.C. for this reason
Date 11—1. 11161V 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 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.
STATE COMPEN-0,141 i WWI fig
(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 sous 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 withthose provisions. �y�• ;
Date: e-2- lyi zid ' Applicant , ?�'�
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 person at
whose request and for whose benefit work is performed under or pursuant to
any -•permit issued as a resultrof 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 authorizelrepresentatives of this City to enter upon
the above-mentioned property fo(inspection purpos1/1
es.
Signature (Owner/Agent)-'��'� f^'"I _� Date ":/"'��' f
WILDING"PERMIT PERMIT#
DATE_ y ,/ VALUATION" K LOT �➢ TRACT ri
,)r '
finnprimun 7.2
JOB SITE { 4
ADDRESS `t'-
APNI
OWNER -
CONTRACTOR /DESIGNER $-ENGINEER y .
CEWIMC k•IMM
C ' '",IR JAP0011 S SPAS crop .$i A14 Col
2.28,0'WARD ' OW Cak2CI4 =W, 150
7472: JOM LYRIM IRM#A '
CA 91720
PALM ALWF- T CA 91260
(760)3 0.9000 M►'a' 355
-
USE OF PERMIT
1?0,0I: 4M/011 WA
S COUSP.AMBQ, .AL ARM'SIRARRIMS SHALL SL "(Isi 3,'fAC-0 AT
PRE-P%Ar"'i1,11INS11.! 'IONt IPOOL MUlPMl:'IJ"i° 1; �XfY.Ld9SUM!, 1400
Pk00LVRD/0R SPA 20DOX0 La
. ftAT M)
PL" CHVICK FEE 1011.000-439.318
CCf8STiWC1'10X FEE 101.100G}- 16-00Cs
N>i't HANICI L WE W- P001a 1011 000^4.21_000 $$24,00
Rg3..�t�.,YYs��.'(TRICA ,. 101 -000 -420 -OW 94 5.al�
jd�p.jjjjIMpP, pPl ��G/OL
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�`.tiUMBINO Y7orE. •• P06.1, I01 -0X V"`P�J.9- ?00 $2710
SEP 11
2®a
RECEIPT
DATE
R. /
�,'-1 1 ,•
BY
DATE FINALEDINSPECTOR
INSPECTION RECORD
OPERATION j
DATE I 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
t 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
BLOCKWALL APPROVALS
Set Backs
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Final
PLUMBING APPROVALS
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Finat
_
9
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
Gas Test
Appliances
Final
COMMENTS:
_
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vothge Wiring
Fixtures
Main Service
Sub PancMs
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)