0104-123 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that*l 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.
Llcartsa uLic. Class Exp. Date
Date e e wz 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:
• ( ) 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.
'( t I have and will maintain workers' compensation insurance, as required by
Sectjon 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, (yy 1, pC pp ppq`} yA Policy No.
�,- P:x''d AI 6Y V�7.44Y"� l.'[ rf4�lEP{p�73UC
(This section need not be completed if the permit valuation is for $100.00 or less).
Q!) I certify that in the performance of the work for which this permit is issued,
I shall .noY employ any person in any manner so as to become subject to the
w6rker's' compensation laws of California, and agree that if I should become
.subj4t fo the workers' compensation prlovisions of Section 3700 of the Labor -
Code, I shall forthwith comply with thoge;prov'sions.�
to v W eh Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensa Ion coverage is unlawful an
shall subject an employer to criminal penalties and civil fines up to $100,000, i ID
addition to the cost of compensation, damages as provided for in Section 370
of the Labor Code, interest and attorney's fees. .
IMPORTANT Application is hereby made to the Director of Building and Safely
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 persont
whose request and for whose benefit work is performed under or pursuant t
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 b ve-mentioned property .o -inspection purposes.
S, ignature (Owner/Agent) pew n Date
BUILDING PERMIT PERMT/t
DATE VALUATION LOT, TRACT
JOB
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN INEERd
c"1;'.NTi.8Fi.Y tR OW.`I COMMUNUMS
C AI.,Ik"d}RRIA IgOOL U & WAS Citi P MAN C01
4
74725 JORT DRIVE, SUM 0A
RAN BRIMARLYA O CA. 92408
PALM i5RUWr CA 92260
(760)340-90M CE1.0 :WSJ
USE OF PERMIT
POOL .r "WOR OPA
PQOWSPA, AWii4 "ARRIE.RS SHAU., .OR, IN PI. ACP AT .PRFo P1.AST11 .
I"C1(77 c F k� U1000.00 LZ
to .? . WAIJe 6.00 L?
RUMIATLM C.` -OST OF C:ONSMUMON
22A .00
PLAN 04PICK F231P $152.10
C ON'S' RAIC T1014Y Y E $23.(19
ABUT H A.i IC.A L ME -- POOL 101.000-I Z I.OM $24.00
Xt��.C.'i II.ICAJ AFTZ, - POOL 101 -WO -420 -OW $45.00,
k'`1,MBINOFal POO;, 101.00019-000
APA 2 0 2001
i
' w
CITY OF LA QUINTA
FINANCE
IYSS P 5' .At+TD n, WKS +
910,00
IMAL MUM PTS DVE HOW
TZ462. i [3
z
RECEIPT 77T�
RECEIPT
DATE
BY��
DATE FINALED
INSPECTOR
R!
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
POOLS - SPAS
_
WE
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
04-
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
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior ReMptacles
G.F.I. "
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Final
COMMENTS: