0204-034 (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
6156128 C:53 MiCA.1' �0n1124
Date Signature of Contractor
OWNER -BUILDER DECLARATION t}
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, wilkdo 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
5
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 ...,-'STATE COMP �: aATI Policy No. D400-006160-01
,(This section need not be completed if the permit valuation is for $100.00 or less).
p'• O 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` compens ion provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
r Date: -4A Applicant j 1:1&1 1
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.
I
IMPORTANT Application is hereby made to the Director of Building and Safety:
for a permit subject to the conditions and restrictions set forth 4on hi
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 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 subjeci 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 property for inspection purposes, j
Signature (Owner/Agent) �•�� I.14 -nate
`
_
PERMT"
UILDING PERMIT
DATE' VALUATION LOT TRACT
JOB SITE
ADDRESS -4062• Sk'.'�E�'501DA"4' APN
OWNER ' -
2280 WJIMX/Glov Le,Bit=I x$150
COR014A \ CA 91720
USE OF PERMIT
1°'f�'J ,014WOR OPA
CONTRACTOR/DESIGNER/
CAUTMOMAPOOL$ A SPAR (TOR WW
74725 J01411 RIM W'17U'AA
PAL,u br-."nmr CA 92260
k -760)340-90M (�aW 00355
ALAR.T HARRIERSSHALL D9 IN PLACE AT PRF-Pl,.A;VfER 1149PECTiON,
PCtOLI�QUT 'UIZNT E'A1CI/.JSUREINOT INCIX139%3.
VALUATION
22, .901431
EMU= COSTOF CClNMUCT.TON
FLAN CHECK Pat, 101-000-439-31R 51425
CONSTRUCTION "Z 101-000-419-000
MECHANICAL FEZ -• POOL 101.000-421-000
ELECTRICAL FEL •- POOL 101-000-420-000 $45.00
k'L'1JMBINO FEE -- i'ool, 101�.QOQ-419.000 12710
ows
p.1l6 Q 6 2002
CITY OF LAAUINTA
:C' MUT 7f:0. S DUr NCJw
RECEIPT DATE :i BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
! OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
POOLS - SPAS '
Steel
Set Backs
_
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
,Final
Gas Piping
4 PLUMBING APPROVALS
as
Electric
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
Fbitures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: