0105-091 (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 Divisi?nr3 oithe Business and
Professionals Code, and my License is in full force andlcvc
License # Lic. Class f j Exp. Date
Sate Q*1 wVU<rj Signature of Contractor ( n
OYVNER-BUILDER
I hereby affirm under penalty of perjury that. I am a empt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employee's 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).
O '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 declaratior
() I have and will maintain a certificate of consent to self -insure for worke
compensation, as provided for by Section 3700 of the Labor Code, for th
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:
Cartier Policy No.
STATS MID 2:194104019334
(This section need not be completed if the` Oefit al'uation is for $100.00 or less).
( ) I certify that.in the performance oVth�' G for which this permit is issued,
I shall not employ any person in any Ima tte otas to become subject to the
workers' compensation laws of Califtornia�,. agree that if I should become
subject to the workers' compensation py yI i ni of Section 3700 of the Labor
Code,, hall forth ith comply with those -'rov ions. .
Date: ° -► Applicant
r
Warning: Failure to secure Workers, orels ation coverage is unlawful and
shall subject an employer to criminal p�enalt4es 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 th's application becomes null and void if
work is not commenced within 180,i1�ays from date of issuance of such
permit, or cessation of work for 180d s will subject permit to cancellation.
I certify that I have read this ap
correct. I agree to comply with
construction, and hereby authl
the above-mentioned property 1
Signature (Owner/
gegt)
state that the above information is
State laws relating to the building
natives of this City to enter upon
purposes.
Date%.
" b w (7) `
BUILDING PERMIT PERMIT #
DATE VALUATION LOT 0105�i TRACT
�1*ItY ��(%/+y�{�� �yyj��
$1 76iSor4 .00
JOB SITE
APN
ADDRESS
371 SWMA VWTA
OWNER
CONTRACTOR/DESIGNER/EN (NEER
HX. I•IA �X dbi V AC�4 st`IN PC OU
79-37) 11"MRAVISTA
95U DONAM001T RD,
.LA QUIWI-A CA 92253
UXT.RM VALLEY CA, 92356
(760.)M-6045 C13W. 43.15
USE OF PERMIT
PM:.R3/irk SPS,
POGUSP.A. , FffaRSliiAKRI.M SHA LL 89 M PLACE ,f T PR&PLAST;f R
MMMON, POOL XQUI ?MENT KNCLOS pPA NOT 11dCLi; DRD,
POOL,k'1Nfi3',JO.i SPS,
X37M OUST OF MRSTRUC7. 0fi
1.SAX).00
i} :N CHECK FLY, 101-000-439-318 00-439-3Iii $105,39.
CON.31rR.UCTION PTIZ, 101-0300-418-000 $16Y.00
MCHANICAL ITS — POOL 101-000.421.000 524,00
ZL_WV.T JCAA., PEC -P001, 101.,000-420-000 $45.00
PLUMBING ir149 - POOL 101.000.413.000 3".0
D k'y Cox'L'� CITON AND F�T..t�S�' �`�"�'CIIBLIK
LM33 -PAMP �+`�
363,30
$0,00
MAY 10 200171: Wr FUN DUE NOW
$30.v
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE'„, S
B.`.
DATE FINALED
INSPECTOR
• r ,
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 Wali 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
Encapsulation
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
� d,
oi�`
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)