9908-081 (RPL)LICENSED CONTRACTOR DECLARATION
. LT7;eby affirm .under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Sectiorr7000) of Division 3 of the Business and
Professionals Code, and my License is in'full ,force=and effect.
Lice se# ILic: Class --Exp. Date
ter. ®tuffs �r''� � r tltSf;3Q1/2(ri
VDate 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): -
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 followingdeclarations'
( ) , 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 workeis'..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 ' PolicyNo.
(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 th—grif I should become.
slect to the workers' compensatio;pyii-ons of. ection.3700oof the Labor
Codetrh II fot lia -ith comply with t'vision
Applicant
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: f .
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 ihis'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 autt onzelrepresentatives of this City to enter upon
the above-mentioned property for spectjo�rvpurposes.
Signature•-(Owner%Agent) r Date
BUILDING PERMIT r PERMIT of -011 w`r
DATE VALUATION LOT. LOT. TRACT
rte' �� 1�Aafl sI%F�
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
RYr H<.all ES LLIC
PO BOX 810.
1425-E. t.�i 'ERBF Y IJROF
L,-QivINTA CA 92253
PHOENIX :AZ 85034
r
f60 )2S'�-9.63 C:BLQ 4990
,
USE OF PERMIT
POIDLAiN YOR. SPA;
" i~"Ui?i.'� 63�'!A, d:T�+i�i.� .:gi:f3ii1F�.Fsi�l�:(�'C?.S. St•Tr�tJii. Id9r :Ldd �.i;elC� .A.T
PRE-PLASMR YNSPECTICN
POOL ANWOR SPA f 0,Ot5 mio .i:3
P...:RMff >&`EKSUMMAR11
KJAN CIMICK M. , $76.05
C:Ca?JSmi}C'CiCao F.E% @19:1 ill 3 • iiiTit $li~..c1il
WCHANIC'A t - POOL, 10.1 -000421 -OW . 9i S:4E1
E e'1'k(CAL:F s _.POQL ,1.01.-000;426-f iD • :t
'd�L:[3t4�i�;F�F,:-:>�OL ' '• ' liJp=O(Da-d91�•dIl1i1 �:��.�3
S:; .tarAL CONSTP%.Lrrz'ION .ND I)LA CHP,'C,.K:.
$289.05
.L 1�:tFflat#)Fi
S�3,:}{)
TOT L E RAHT FEES DUE NOW _
S299.S
III
RECEIPT
DATE '
BY
DATE FINALED
INSPECTOR
.a
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
BLOCKWALL APPROVALS
POOLS - SPAS
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 Piping
Gas Test
Appliances
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.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: