9904-088 (RPL)(
LICENSED CONTRACTOR DECLARATION
under penalty'of pe4u that | am |kmnood under provisions of
lri a p . ter 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
?Signature of Contrac
Dd/te 14J,
OWNER -BUILDER DECLARATION
| herebyaffirm under penalty ofperjury that |amexempt fmmthe Contractor's
License Law for the following reason:
( ) |, as owner ofthe property, o,myemployees with wages aotheir sole
compensation, will dothe work, and the structure ionot intended o,offered for
sale (Goo.7o44. Business uProfessionals Cuua).
as -owner of the property, am exclusively contracting with |ioanood
contractors to construct the project �oo 7044. Business & ProfessionalsCnUe). . ^ .
(>|omexempt under Section BuPC. for this reason
_____�__
oate SignatureoxOwner
WORKER'S COMPENSATION DECLARATION
'
| hereby affirm under penalty o!J-perjury one of the following declarations:
()| have and will maintain acertificate o,00na��maemnovmmrwonm�'
compensation, as pmfor by Section 3700of the Labor Code, for 'the
performance orthe work for which this permit ioissued.
( will maintain workers' compensation insurance, as requiredby
Se6tion 3700 of the Labor Code, for the.: performance of the work for which this
permit is, issued. My workers. compensatio . n insurance c . arrier & policy no. are:
Carrier Policy No.
(This section need not uecompleted nthe permit valuation ivfor $1oo.000,lexu.
( ) |oortify that inthe performance oxthe work for which this permit iaissued,
| shall not employ person in any manner oo as to become ov�o�mmo
workers''compensation laws of California,should become
su�.ect to the workers' compensation proyisions oJ,Section 3700 of the Labor
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
�ddition to the cost of compensation,: damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application iohereby made mthe Director mBuilding and Safety
for a permit subject to the conditions and mot,ioUono set forth. on his
application.
1.Each person upon whose behalf this application ixrnmUo&-oouhperson ox
whose request and for whose benefit work ioperformed Linder orpursuant to
any permit issued osoresult ufthis app|iosoonagrees to, mshall, indemnify
& hold harmless the City of La Qvintu, its o#ioom, agents and employees.
o.Any permit issued aooresult cdthis. application becomes null and void if
wv,x is not commenced within 180 uoxu from uuto of issuance o, such
pe,mit, or cessation ovwork hm,'1oodays will subject permit to cancellation.
|oemfy that | have maUthis application and state that the above information is
correct. | agree mcomply with all City, and State laws relating mthe building
construction, and hereby authorize�representatives of this City to enter upon
BUILDING PERMIT
DATE VALUATION LOT,' TRACT
JOB SITU
ADDRESS
APN
OWNER,
CONTRACTOR DESIGNER ENGINEER
MW
LA QUINIA CA V.12-53
PHOENIX A -Z 85034
USE OF PERMIT
PM -PLASTER I'NSf4FCr1(3N
POOL ANDIOR SP,& IS
PERNIff FEZ SUMMARY
IXS'S AR.R.PAID FEES
10,00
BYJ
DATE FINALED
INSPECTOR
t
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
Steel
POOLS - SPAS
2
Set Backs
Electric Bond
2,
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
/.
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
-y 0,27
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
(f -
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notic . (Perm)
COMMENTS: