0205-256 (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
Y .600 4MO104.
-,
-'
Date /L?—Signature of Contractor f
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 :S'AY4 FUND Policy No. 2"42900
(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 3700,1611 the Labor
Code, I shfforthwith comply with those provlslons- -� — a--,
Date: �' Applicant •11, f moi' -M i ': /
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.
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 in.+'ssppec�ti/on.,purposes °l
Signature (Owner/Agent) `� w'%° -`` Datet
PERMIT#
s L -BUILDING PERMIT
.
A&& VALUATION LOT d• TRACT
JOB SITE
ADDRESS na�`5 ;F�.V..L`YMA, ��..?.A�rSM
APN
OWNER
CONTRACTOR /DESIGNER /EN61NEER
-
IXOI tB
(aL-CgF' y)dyr01,Sa A1^?Y.
13-96SFRINW3tELA`iCO
I0-IStrHLMROAD 03
1A QttIN AS.CA 92253
RANCHO MXXtC Ck tt22,!0
(160)831.10860 MIA 3 759
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,
USE OF PERMIT
POOL AMM SM
POLIL AL,AAMSMiA "ERS SHALL kfiLp M PLACE AT PlfiZPLAS` F_R
NSPW.1100, 14 L F. 4` 1001, EQUI:PUMT MIC%.OStii , VIAL7 CITY'
4 .FT. WALL K00 LF
VAJ,i3ATIM L -S
PLAN MUCK FEE 101 -000-439.318 510130
CONSTRUCTION FRE
FJ,FCTPJC-AL M. POOL 10Ia000-4ZO-000 MOD
PLUMS= ME .• POOL 101--000-419-000
AICD PIAN E'°E.rl M
MAY l.. 1. f rwwm n s D`i F NOW
�. 9130
CITYOFLAQUINTA
FINANCE DEPT,
-;
RECEIPT
DATE =
BY
DATE FINALED
INSPE
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
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs L (L
Electric Bond
1_
Footings
Main Drain
Bond Beam 7
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
i
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
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)
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