0201-150 (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
61.561 . (:53 �C-8 J7 �V-3i/004
r , � % f
Dat �"�� " -" Signature of Contraetgr'- '' ry ��.:`�'?
'r r 1�
OWNER -BUILDER DECLARATION FJ
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 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.
`( ) 1 have and will maintain workers' compensation insurance, as required by
4k•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 STATE CC�11&tfN,q'A�D Policy No. 046-02 000,06168
(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,13700 of the Labor
Code, Ijshall forthwith comply wit :fhose-provisions.
Date: /���' Applicant �� /'"".��'
ell
Warning: Failure to secure Workers' Comp= coverage is unlawful and
shall, subject an employer to criminal penalties and civil fines up t'o' 00,000: i
addition to the cost of compensation, damages as provided for i' . 'tion 37t,
.of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Buil d Sift i
for`.a permit subject to the conditions and restrictions se rt o Is
application.
1: -Each person upon whose behalf this application1s made -& ch perMtOf
whose request and for whose' benefit work is,performed under r ur r�f 801
any permit issued as a result of this applicaton agrees to, & s , 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 authorize representatives of this City to enter upon
the above-mentioned propertyforr inspection purposes.
r .
Signature (Owner/Agent) .�. �-�+- � � '1 �•�Date �•''
BUILDING PERMIT PERMIT#
'
DATE :L'_ VALUATION LOT TRACT
JOB SITE
APN
ADDRESSa�li6 ,V)? .t .l c
OWNER
CONTRACTOR / DESIGNER / ENGINEER,
(.11 7' .K H'0;Artt ,
CA7:.B)ORN'!A:NCat` tZ & SPAS TDPC101
2280 NVARDe OW CIRCIA SME 150
74725 ac N1DRT_W.?s;RTn #A
CORONA CA 41720
PA M. DMRT CA. 92260
Ci ) 4 j-9000 C' .d 00355
USE OF PERMIT
i*00L AiND/01R IVT.
POWSPA, CTAS STLYB, RLtQ (AM) Z21 5&-109.5) ALARK;
}3Tt�,1Ri1 S1'1J,t,tate ]Td PI.Af�..�,1' P1't�lfi1?121ivPCf't03�. POOL.
EQi3'<t't+FiFNT ", 1C'LOSLTM 140T INCLTJT.Y W-
POOt.,.fi:PJlXOR uP l9,Qt?.�,DiJ v5
FIMMU tom. °��" .UUMMAR I'
i'.fAM CHECK PER, 101.000.439-318 SIN,70
:.'ONSTRUC'.fIOV FEE air -000-419-000 $199.00
mn-u vICAL, t _ poota 101.00042 1 �000 24.00
XLZCTR�C:4L kV, - K)01, 101-000-420-000 $0-. 9
PLL3tJ113NO VEE-•- POOL 101.000.439^FJtIi) srhoo
a
LA QUINTA
.r IM -TOTAL M)dMT"1OH MNDeY +ECIC
$422300
LLM PRE PAID RIM
x,00
TOTALL nMW MS DUE NOW
RECEIPT
DATE
BY
DATE I LEp
I S CTOR
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
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
-
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:
4t