0204-173 (RPL)i
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed und8% N.i; .�. S 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
Date Signature of Contractor r*
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following rea• .son: ^
( ) 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). w
( ) I am exempt under Section , B&P.C. for this reason
'bate 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.
( /) 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 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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with tho e7provisions. �1
Date: r ! a94-1_ Applicant r"� A � .,
Warning: Failure to secure Workers' Compensatiofi coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety'
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at"'
whose request and for whose benefit work is performed under or pursuant to .
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its''officers, agents and employees.:
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City; and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purpose.
Signature •.(Owner/Agent) , _ �i'�'= Date
1m
0, " PERMIT#
B'U'fLDING PERMIT
-
DATE VALUATION novo LOT, �TRACT
JOB SITE
ADDRESS tenli- 1 SPi .Y 9
APN
OWNER "•
CONTRACTOR/ DESIGNER/ ENO INEER
CAUFORMA44OOLS, & FWASv CrOP MAN a
ORY -
74725 Z OR WIS, LKWI +` AA.
PAW i:9E. EW11' CA
.%2260
USE OF PERMIT
POOL ANDfM SPA
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ILIK .WLI'ELI LYW$
PRIUM FEE S1, U, MIARY
PLAN (ANCK FEE 18 $123 SS
(I43N8'.i_i.�1LC'1`10N M 101-000-418-M � a
POM 191-00,491-000
HLE r A.LF -- ter, 101410420-M S45AX)
°e Il
10 C,0N&F2UCq)0N A14D PLAN CHICK
U99 PRE-PAYD FERS
$407.'85
10-00
APR 2 4 2002 oa �� -IT Wes
CtYYOF LAUl A
FINANCED ,
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RECEIPT
DATE
III
tBY
D 0D D�
I PECTO
I
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
Drvwail - Int. Lath
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underaround Plba. Test /..
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
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice
COMMENTS: