0103-211 (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 Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # '' Lic. Class Exp. Date'
13 C 7 W/41/2:
,Date ° f%' 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 the
performance of the work for which this permit is issued.
(I ) 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.
�11:a✓�i�.�3`�A:Y' 11Dft�3-69-�
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
/Code, I *shall forthwith comply with those provisions.;'
Date: r Applicant-
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawfill and
shall subject an employer to criminal penalties and civil fines up to $1 in
addition to the cost of compensation, damages as provided for in Se t n 706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building Saf, ty
for a permit subject to the conditions and restrictions set foron is
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed Linder or p rsuant to
any permit issued as a result of this applicaton agrees to, & shall, ndemnify
A hold harmless the City of .La Quinta, its officers, agents and e
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 propertyfor inspection purposes. f%
� �
Signature (Owner/Agent) _/ / Date' '
BUILDING PERMIT PERMIT#'.
DATE • VALUATION LOT TRACT 7
-JOB SITE ` �"'^- --
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
;i?C.�" MOT., IS uqc
DEM.RT CO"bio aCT=014 '
41355 Y'[7C-Uk L,ANZ
PALM DUE= CA 922.60
BERMUDA, IY ,4VA Cain 92201
(`760,)a60.4400 CB1.6 3046
USE OF PERMIT
POOL AND/OR. SPA
1110OUSP 0NL-f-A7..ARMS8ARP. En SHAW, BE IN PLA. irAT
PRE-itLASTI&R. iAlSHM"gION, POOL E+Qrfit l UIT [INC.`3.aC SUltE TO NOT
MCLUMD IN THIS PERMT.
POOL ANDOR SPA W
EgSy7tM4 :QST or COl!�T"�"'!'�:>ti£ off
ffi..iL' 3.it'if,N8:4 I1S� �r� X
LAN CHFAX FRE 101.000-131D-318 9103.30
CONSTRUCTION FEE 101-000-418-000
MECHl+NWAL,VEZ..POOL 101-000,421--000 SX00
ELFCTFJ' A' L FES - .P001, 101-000.420-000 $45.0
PlaL!'RiS.1D3't O "M -- POOL 101.000-419.000 S127.010
W O
PR 2 2001
CITY OF LA QUINTA :31 - '( .AL+v'-C)�!' i .Il'MEO.N'AQ3'?J lei# HCI CC
FINANCE DEPT 1=3 PRE -PAM MES
$000
TUTAL 11rKRWX MS DUE NOW
RECEIPT
DATE/ j
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
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
PLUMBING APPROVALS
Gas Piping
Gas Test
_
/l
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
ow Voltage Wiring
q -.Aures
AF., in Service
S'ub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Utility Notice (Perm)