0103-056 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby a% 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
69075 C33
Date'p"°t +t
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 Vie
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 Policy No. `'
I-PTATFI RIND 10,107-00
(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
subjefct:to the workers' compensation provisions of Section 3700 of. the Labor
Code, I shall,forthwith comply with those provisions. 'p ax`
-Date: A', Appllcanf..
fir,; �' 4! �;••iia-.;-s....�.-:...............
Warning: Failure to secure Workers..Com4nsati' nh cov_e+.rage Is unlawful and
shall subject an employer to criminal penalties and civil fines up to $10000, 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 his17
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 inspection purposes,.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01.(r '�W. TRACT.
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M.' I1111-1 0
int tE PALM EWtENIMSE-3
710-652 MENACOURT
8 196 MiOW£AN VIEWIJANE
I.A. QV:TRUA iCA 92253
LA Q{7NTA SCA 92253
(760p91-5310 Crilliff 1888
USE PERMIT
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P4:Airtid.,'PA. A LAR ? R4`S.e RRIF RIS SHALL BF,, IN K AC J'?, AT ;PRF PLAS T °R
WSPRCTfCiX. POOL 0-OIPMD4't CNCLOStfRP,' )v0T I14Cf.UDED .
POOL ANIVOR> PA Ls
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V.577MAIED COXf OF CsOF' 9MUCTl.7O5
RayO�i.�I
MARY
KNN CHECK FEE 101.1000-439-318 $105.30
C.`ONS11111t€C°`D'ti'.91N ME '101-C1Ut} 18-000 0610V
MEC9fMICIAL "19 P0014 101-000.421.000. S2R,ft4
EL MCA FEY — POPP� 10'1-000m.20-000
PLUMBY`HO FEE F. x'001, 1.011.-000-419--000 9,17.00
MAR 12 2001
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OUB-TMAL CONS 11RU5.'"1ION MD W -M CIMIX
$363.10 m
USS M -PPM FFM
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a1b�.M�'ar'yV
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
V..
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
et 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
-Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
Pool Cover
Sewer Connection
Encapsulation�—
Gas
(Dl1f-j
�� r _Z�
�G`
Gas Test
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)