0002-329 (RPL)LICENSED CONTRACTOR DECLARATION
14i�Vrn 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
0
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tS d)3P3i.�2CN
Pate% -Il 4'l,� Signature of Contractor—' -A A' � f/
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 VX—LUN FION ON 1. LU , Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( t� 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
C de, I s all fo hwith comply with those provisions/.j
C
> LApplicant it
Warning 1 Failure to secure Worke s' 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.) agree to comply with all City, and -State laws relating to the building
-constr6ctlon, and hereby authorize representatives of this City to enter upon '
the above-mentioned property for inspection purposes.
+Signature (Owner/Agent)-=F A !. 1 _ I �`. t/ ). viii' bate—') > '
.BUILDING PERMIT PERMIT# ,
(M -3z9
DATE 2(14)VALUATION %1:5,00Q.04) LOT TRACT
JOB SITE ADDRESS 77••160 CALLE SIVA 1�A
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
JACK. CLM1 K
JACK'CLA M 004".1' RAL AC :01:
51-220 A'VM[DA CA RfUQq&k
51-22.0 A ENIDA CAR-RiVNIZi
LA. QUINTA (,A. 92253
LA QL. ENTA CA 92.253
`
ly6f?j5 4- 511 C;K4 111:
USE OF PERMIT
1
L'(., )LMC?iOkSRA
POOL & SPA ONI.: s - LALAt2Wei2.ARRIE IS S14Ai..1. RE 111 PLACE AT
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is EC'''11sA'.NIC'A,`..1'T:.t; -- I'•t?OL 101 .'1t1n4`400
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5363.30
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RECEIPT
DATE
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 i — 3_ 00
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
119
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
i
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
6 %