0110-054 (CP)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. Date .
C53 MC C-8 10/31/04
Date al �1 65ature of Contractor—
OWNER-BUILDER
ontractor OWNER -BUILDER DECLARATION
I hereby aff inn 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 bf consent to self -insure for workers'
compensation, as provided 'for by Section 3700 of the Labor Code, for the
perfori�.nance 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 9'IATr Policy No. 1�414£►�163
(This section neednot be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the, work for which this permit is issued,
I shall. hot 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 sha`If f�rt4ith comply with those provisions.
Date: Applicant ct.
Warning: Failure to secure Workers' Compensation coverage is unlawful and-
shall
ndshall subject an employer to criminal penalties and civil fines up to $100roo, In
addition to the cost of compensation, damages as provided for'in-Secti �06
of the Labor Code, interest and attorney's fees. U
t
IMPORTANT Application is hereby made to the Director of Building an Saf ty
for a permit subject to the conditions 'and 'restrictions set forth onis
application.
1. Each person upon whose behalf this application is made & each person at 'CC
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 alf City, and State laws relating to the building
construction, and hereby authorize repreMntatives of his City to enter upon,
the above-mentioned property fo Inspec or u se .
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT# `
DATE VALUATION t LOT TRACT
17
JOB SITE Aty APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN INEER
2280 WARDWW CMICItaE, SST! ".150 74725 J01H MAT, MNTV, 0A
CO2+ UNTA CA 91720 PALM D EURT C'A .92260
(76aY340,-9000 M.%# 353
USE OF PERMIT
I,L OUSPA.AlAt:M:. IDA.12MR.S' SHALL BE 114 PLACE AT PPaloPdASTER
PC7OLAkbWO"i.R SPA
I9,5£Ip.40 is
I3I. A:N CHECK FRE X01.0-00-439-318 S3ArSo
CC►'N' 4•'u "C"ThIDN FEE 101-000-419-000 $261.09
M X(11.RANICAL FRE, . • POOTA 101.000-421.000 $24.00
91=A RIC ^A1r FEE POOL 1 X31-WO*42s -WO X43.03
PLUMMIG FRE _ POOL 101-00-419-000 MOO
a• t
.04 2001
N,
OF LAQUINTA
itXC r) _ PT. .A'£ IR k'3iJilt atm
RECEIPT DATEB1 DgFIN
i
fxD (I r„fir _—
.1915 .00
.$T10. qq00
�o�YieeJaR �.
R '
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
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS
�� 1 W •
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
_
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
WateriPiping
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
�c✓1 ��� —_� _
f.
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) .
COMMENTS: