0110-050 (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
0151a's C53 FfIC
Data A 2: Signature of Contractor-
OWNER-BUILDER
ontractor 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.
C�,( ) .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 aSTAyi? Policy No. O ST
1 .
(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 these pr��vis ons. /
Dater/ ,::E' ` Applicant
Warning: Failure to secure Workers Compensation coverage is unlawfu4I- rad--
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 Sectio l`1706—
of the Labor Code, interest and attorney's fees. rf
IMPORTANT Applicationis hereby made to the Director of Building andLhs
for a permit subject to the conditions and restrictions .3et forth application. 1. Each person upon whose behalf this application is made & each pe
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 permitl�to..cancellation.
I certify that I have read this application and state that tje 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 ' 1ispection purposei;.
Signature (Owner/Agent) � d` Date��t��'�
BUILDING PERMIT PERMTk
DATE VALUATION LOT TRACT
JOB SITE V
APN
ADDRESS )p"1 bAy
OWNER
CONTRACTOR / DESIGNER / EN (NEER
t`w"rX.F99 How's
i"ALTFC3RNIA I3'0C1LO &81 -AS (T01) MM MT
2=0 WAZuow t�.= ,m J,)
7025 JON I D111VIE, b;rii7%U 0A
CORONA CA 01720
:1'AL.MOH8L,0 CA 92260
(760)340.9000 - mmg 353
USE OF PERMIT
ro0 % 1,i Df01Z 31:fit.
lh'.00ILMA, EEE N 9" L4C-E', AT PRY..- PLAa" i'ET:
INSPECTION, POO.L EQVTPW.K4T MCT��ItvF E NOT INC1,UDED, GAS AND
L'Lf.'.CT?t.IC:TYURSFOIIFUTUPY,BBQ -ANSI Z21•52.1995
FO01, AWDIOR S?.iA,. 19.1501.00 L
.Wi31YMOUD coippA. F mirtimnof
? AN CHWK F 74i1d0 ?•4a ";J $134,33
CONSTRUCTION ION 101-000-418-000 $207.00
MECHANICAL FES -• POOL 101-0004421.000 $24.00
'
1 LY',C PiC,4I. POOL 1011-003.420-000 ikJS.AA ,
P1.444,81NO F92 . POOL 101.060.4 J a9�000 327100
CT 0 4 2001'
'TY OF LA QUIWA `
-
FINANCE DLPT.
RECEIPT
DATE r f �l
BY
DATE FINALED
INSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
s�
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
I
COMMENTS:
Final
Utility Notice (Gas)
;{ ELECTRICAL APPROVALS
Temp. Power Pole
Ung., --ground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.FJ.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)