0103-239 (RPL)LICENSED CONTRACTOR DECLARATION--
I
ECLARATION„I hereby affirm undeFrssBnalty of perjury that I am licensed under provisions of
Chapter 9 (commer6'ing with Section 7000) of Division 3 of the Business and
Professionals CA, and my License is in full force and effect.
License # - Lic. Class Exp. Date
fj stb 26t 4:'53 HIC: Car 1A��
Date �r 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:
( ) 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:
( f 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
Secfion 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.
(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' compensatioyt-provisions of Section 700 of the,Labor
Code 'I sha orthwith comply with dose proy' ons.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is un LtyN
shall subject an employer to criminal penalties and civil fines up to $1
addition to the cost of compensation, damages as provided for in Se
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building Safor a permit subject to. the conditions and restrictions set fo on
application.
1. Each person upon whose behalf this application is made & each oerson at
whose request and for whose benefit work is performed under or pi irsuant to
.any permit issued as a result of this applicaton agrees to, & shall, In emnl
& 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 witWall City, and State laws relating to the building
construction, and hereby But prize representatives of this City to enter upon
the above-mentioned prope y fer tLnsp dtion urp sea. '
Signature (Owner/Agent); �9 Date s` w
BUILDING PERMIT PERMIT#
f
DATE �. iM -VALUATION LOT ?(��(J�-°��� TRACT
i ..
JOB SITE ;0,
APN
ADDRESS, '
180 -Wo VAMSH BAT
1
OWNER
CONTRACTOR / DESIGNER / EN INEER • ��+;>,'i'.,
CEN 'krX Holds
CA%&O7(N A POOLS: SPAS (TOP 1AW'C 01
2260 WARDi OW CMC: i., "abLUM 160
74125 .TONT DR^ WAM+A.A
C?GtiRCCKA CA 91724
Prrh�ryry&a���jSgJEySE��R(�.'�1 ';'C:l�ryry'���,,ttt211`.��.W
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` 60)3413^F� O '� cnff ^
USE OF PERMIT
PC?GI 11A. 88Q. ANSI ad•M1383..At.AMSIB ARRIHMS 5111.0,11.
ply+�!y�e1���fFY�1.L�la.At'a17'g11c�rrt ��p�A!y,��It�>!g{L. yy-
S,.G 1AX,i§. b4Y.f 1,L. l..IT S S'.diV7..�ARMo '
W10011 t"iPiWOR SPA ;fi,00U.00 t ,5
3 FT. W AL1, 5.00 U?
ESTMA ..9 COST 01F C ONS 13';; "nON
P304MC IMS SUMMARY
V'1a&N (111MCK FEE 301-00-439-3,38 $140,40
MECHANICAL IC AL i129 n. ,iaMX 101-000-4244400 $64.00
E UMPWAL 1FRK • POOL 101.000.1420.000 $45,00
C°:�BS;�'R'k3:���1G1�13?FDS 1CTp.�i9E10�4%k#y(i'et� t��a.t!tl
AY 2 5 2001
CITY OF LA QUINTA
FINANCE DEPT . CYC9k 3�1%LT S iC�1 fia,inP��1'' cime2C.
$461 A0
1X03 Pn-PXDFM
$0.00
DUE NOW
r
W1,40
RECEIPT
DATE %
BY
DATE FINALED
INSPECTOR
/
' Y • • , YMvelm
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
"'ab 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
POOLS - SPAS
Steel
Electric Bond /
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Undergr
UDS,-, Jround Plbg. Test
Final
vas Piping
PLUMBING APPROVALS
Waste Lines
Water Piping
Gas Test
Electric Final
inal
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
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:
,