0904-276 (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
012 9 T .9 C-455 NMI 104
r5
Date i r' r 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.
( ) 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 Xf_+VfXe?3SAD Policy No. '170813.03
(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 those provisions.
Date: f r Applicant
Warning: Failure to secure Worker 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.
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 pursu
any permit issued as a result of this applicaton agrees to, & shall, Inde
& hold harmless the City of La Quirita; its officers, agents and employ
2. Any permit issued as a result of this application becomes null and vo if
work is not commenced within 180 days from date of issuance of s
permit, or cessation of work for 180 days will subject permit to cancellati n.
I certify that I have read this application and state that the above information 's
correct. I agree to,comply with all City, and State laws relating to the buildi
construction, and hereby authorize representatives of this City to enter upon
the•above-mentioned property for inspection purposes. ,
Signature
(Owner/Agent) Date
' ;,;BUILDING PERMIT E�RMIT`#_�
�
DATE _ ,� _,VALUATION LO J � f TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR•/DESIGNER /EN (NEER
iRA00. BRIM ��
;> , � T!;?`.3� i:% e. F•
5:�
P.O. BOX 106A }
USE OF PERMIT j
POOL: ANWOR SPA.
r
f'r:�lty,�lgytSi'7.1gyy94p17.Sr5[`�'�S', i�jdF,.y9'�4'giC197�J�f1i�L'�:{::pUG('f1yi��ir. of-rIp .
�,IwTJ'it,"
�9 [y{ p .�+y�
STANDARD. ,!'T.1�74�i=�Al,�e�'..1�4L't�lr7 fl.!"�.d W, BE IN LLtf'Liti�i.`.f.'i PR9- L A'.'•.�3.RR
4yy�,�/!rr.. i2.G{�Q )IF
:c.
yy jt�Gi�t'Yi..,
ggiyy�� �1 SAE
NV
'lus
.40R
tv'fTA.;
.��1�T~ ^�wtpL�•
Pyy�
p�9��.i����,
d�pp77
i;'.O?dST RUC:'! 101PI MCI 1 O 8-01Ni �"� ��,06
M1E:C?TAi`iyC,.'17.,1?RE, -., POUF ;01.000.41.2' -VCf $24 1.10
r
41.WTR1CAI, MY, — "'0011 10 t :000-, I qtr` -006 = MOD
PLUM+T>Jl.040 FRE - Pt? S. :,W-000419-000 SAM
t
dE •
�. ;l:.�!.L �`,�'sR�I�J �fi TOT1G1' AM) PLA f:'.0 t "� �
$511. gU
VIM 0 5 2003 WFAL1s0-E✓,MUI1i7Z9D��:N0W
���IA)
IJP QUINTA
Of .
CIF ANCE DEPT
RECEIPT
DATEBY
DATE FINALED
INSPE R�
63
J.
N, ZI :104
e ►M 4
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
—
Electric Bond
Footings
Main Drain
Bond Beam
— — Q
Approval to Cover
l.✓�'
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test 00, 0
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
COMMENTS:
Final
Utility Notice (Gas)
' ELECTRICAL APPROVALS
Temp. Power Pole
t Inderground 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)
04
Pool depth 30 to So to 3'
House
Block Wall
lExisting Block
Pool depth 30 to So to 3'
House
Block Wall
lExisting Block
MR. & MRS. Bret �.
52560 Ave Velasc
La Quinta, CA 92112T
771-6889
413-3816
CITY OF LA QUI
BUILDING &SAFETY rD.
APPCONSTRUCTIROVE 10
FORC
Garage
IBOB
—701
New S' Block Waill-I'M
9
10'0
30'0
I �0
01"
ITZ
MR. & MRS. Bret �.
52560 Ave Velasc
La Quinta, CA 92112T
771-6889
413-3816
CITY OF LA QUI
BUILDING &SAFETY rD.
APPCONSTRUCTIROVE 10
FORC
Garage
IBOB
—701
New S' Block Waill-I'M
9