0106-310 (RPL)LICENSED CONTRACTOR DECLARATION.
I hereby affirm ,under penalty of p6rfury,that I am licensed under provisions of
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Chapter 9 (commencing with.S66floh 7000) of Division 3 of the Business and.
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LU Professionals Code, and my License 'is in full force and effect.
:5 License # f Lic. Class' Exp. Date,
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LU
r- 0102
IC I
t- W C".5 J
Z Date Signature of &Gacto
CID
(P I OWN ER -BU ILDER ?DECLA,RATION
LV I hereby affirm under* penalty of perjury'that I am exempt from the Contra tor'
CL License Law for the following reason:
Z 1, as ownerof the property, or my employees with Wage's as their Sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044,' Business & Professionals Code). A
I.,as owner of the property, am exclusively contracting with licensed
contractors to construct onstruct the project (Sec. 7044, Business & Professionals
Code),.
Cl) O I am exempt under Section B&P.C. for this reason
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C\1 Date —Signature of Owner
0.C\1
WORKER'S COMPENSATION DECLARATION
Z
1 hereby affirm under penalty of perjuiy one of the following declarations:
Lo < cc, , - -insure for workers'
, Ft - 0. 1 have and will maintain a certificate of consent to self
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compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J _J ..performance I o f the , work for which this permit is issued.
J < ,,
00 < I have and will maintain workers' compensation insurance, as required by
O P F<: Section 3700 of the Labor Code, for the pe I rformance of the work for which this
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0) permitJs issued. My workers' compensation insurance carrier & policy no. are:
'�T Z Carrier Policy No.
cb Z) rA.7w FUND 229-61 IJ141T MON)
< (This section -need not be completed if the permit valuation ation is for $100.00 or less).
I certify1that 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 th e provisions
Applicant ant_- 01 e
701h.oilmz- .
e to secure Workers' coverage is unla .1 and
Wa_rr_ni_n;rFFa ker�4
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shall subject an employer to criminal penalties and civil fines up to $10 IMO, in
addition to'the cost of compensation, damages as provided for in Sectioril-31706
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 persoA 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, indem�nify
& hold -*harmless the City of La Quinta, its.officers, agents and ernploy6ei.
2. Any
permit issued as a result of this application becomes null and void -if
.,.wo-rk.;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 represgntatives of this City to enter upon
the above-rnentioned property for inspection purposes.
Date
Ze&
Signature (Own g
A
I I . PERM IT#�
BUILDING
PERMIT.
DATE VALATION LOT 0106-310 . TRACT
19
JOB SITE'
APN
ADDRESS
HILL41
OWNER
CONTRACTOR DESIGNER EN (NEER
161 UOUMMN Bolu
7 3•9 6 OM ITIMAY 131, =TZ 5
1A QIY"rA M 92233
I
PALM DEMI CA
USE OF PERMIT
1`,�00L 16-MIOR SPA
100USPA, ALARAUTIATUZIPAUS SRHALL HE 714 PLACE AT PRF, -PIASTER
INUP90310% POOL RQUIPWIRMT EXCIAWN& NOT MCLUDED.
POOLAMORSPA 17,000.00 La
EFUNAIND COSM 01l'o-VW. 01q
:VrOafff" SUMM&RA?
PLAN CHECK FU 1.01-000439-318 $117,00
CIONMIlZUCTION "OVE 101-1000-418-000 $194.00
W41UNKICAL VEZ --FOOL 101.000-421�000
W,CTPJ(tAL'VF;E - POOL $45.00
PLUMOTHO "It — Pool,
Lr -u
D
4 SEP. 18 2001
CITY OF LA QUINTA
FINANCE DEPT-
13-Ta.rAL C,'0XMRUCX10HAND PLAN CTMT.
3.00
IMP YRE-PAW FM
$0100.
1 Is 10TALMRIff.rFm DU E Row
RECEIPT
E
BY
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
i
Final
Final:
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS -SPAS
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL'S
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
lumbing Top Out
Equipment Enclosure
r Pans s
O.K. for Finish Plaster
Lateral
4_5Connection
Pool Cover
Encapsulation,
_
Gas Piping
Gas Test q
Appliances - f
!
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS -
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.FJ.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: