0104-019 (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.
L'IC8i1Si3 # « Llc Mass Exp. date
6561 1 10;
Date z Signature of Contractor r n
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.
( � I have and will maintain workers' compensation insurance, as required by
Sec46.h 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurknce 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' compen satio,n-provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those prOvisionsfy
Dates ,'' / Applicant-
7
1Warning: Failure'to secure d6rkers' Compens ion 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 foJ inspection purposes.
Signature (Owner/Agent) �� + Date 56!!!q •'
i ;cam
BUILDING_ PERMIT PERMIT#
DATE J VALUATION LOT 0104-019 TRACT
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JOB SITE `
APN
ADDRESS �¢,�t a�. ��• vt Lip T 7*:
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OWNER
CONTRACTOR/DESIGNER/EN &NEER
C'EMMY Cul C?WELL C£7M.!Af�.:`NM
IC AM',ORUJAPOOLS & WAS (IY:)F MAN 001
1 M15 SO, 17 U.ME ', 51% 02W
74725 J CM :f DR Pa, 3UrrI, O
H-Wl BRIMAR iINO CA MOB
PAZI.&ADERIMI CA 92PI60
Q60�,,140m9000 MW 355
USE OF PERMIT
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PCXI3.APMBQ..ANSI Z?1-50.1995. AJE &M.SIBAFtd,'. ERS SHALL BE IN
FFLAM:r1.T PARE PL,ASTER..IMS- ECTi6i. 91,F, OFY ffloi Ruxag,
WALL
PC14' L ANWC<.R SPA 2Z000,00 L's
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PLAN OHXX FBE 1101-000-439-319
CONISTRXICTIOX FEV 101-000-4-18-000
MEV,)HAVIC L FEE -- POOL 101 -OW-4 21-000 $24.00
:6%.1rf=°7CR1CA1. ME — POOL. 101.,7€ O.42( 00 $45.00
P1.MADYNO M -- POOL 101-000-419.000 327.00
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APR 1 1 ?001
RECEIPT CITY OF LAWFA i ;
FINANCE EP1 f e! P
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B.Y '
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DATE FINALED
INSPECTOR
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Sewer Connection
Pool Cover _
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
Ff-Q71 E E W__:
COMMENTS:
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)