0102-172 (RPL)LICENSED CONTRACTOR DECLARATION
�1-hereby..affirm uncle ,penalty of perjury that I am licensed under provisions of
Chapter.9 (c6 men Ng with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
` License # Lib. Class Exp. Date
�3�" • F C2.7 �;ti 07/31/2(.
Y0fl
ate _ Signature of Contractor`
r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's.
License Law for the following reason:
( ) 1, 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.
F() 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.
(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;torthwith comply with those provisions?”
,Date: e?: Applicant A144 -•L: r...• -
Warning. Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on --.his
application.'
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to.
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
i Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
"" permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information' is
correct.._l agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property, or inspection pu poses.
signature (Owner/Agent) c ' �.- -- -""" - Date' ,, "
i
BUILDING PERMIT PERMIT /7
t
DATE" VALUATION LOT (ji°�,.•`%' TRACT
19
JOB SITE
APN
ADDRESS M�ppgg Yj¢� l�j���1/gy
OWNER
CONTRACTOR / DESIGNER / EN (NEER -
- -
74.19233'10VELYLANE MOTDUTYE2'42,0
41555 YfiTCC LAITE
MW DFIM i CA . 92260
BERMUIi A2,�t�Dgqi�'UN Wit. 92,:�,,�u201
(760)360-4400 45!0 I 64�,LJTY' gi746
USE OF PERMIT
POOL AMI 'sR SPA
X)01P.;PA.AtLAR_MSJ8ARXIF,R3 SI-LALI, HE 114 PTAC9 AT TIME OF
P"RE41 ASSITE9( b1+9(3FMYI0N. KV.L 9<QitIPM11M MC:.LOSURE TO NOT
rAC''IAIDED.
z OOLo.F°iXG1#G3R.-`aIPA L$
PRRXHr VW SUMMARY
PLAN MCI", FEE 101.1100-4439.318 80,75
C,014S'1'RUCT101li RE 101-000-418-€ 00 $195.00
MECHANICAL MR -• POOL 101 -000 -421 -NO •(1 O U4,00
111LEC•' IUCAL. mt — POOL 101-000.420-000 VISA it
PI.fE1R BM0 FWA • POOL 101-OOD-419.000 727.00
i
1
Y
(x,'t RAVTTAT� C0N%tZUC 11:0 AND P'TL<At; MEC
$318.7
a FES 2 ? 2001 »A3G.P � ���,S DU� MOVs1
011%%5
RECEIPT
DATE J
BY' ,'
DATE FINALED
INSPECTOR
`fr,.
INSPECTION! RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
&Footings
Ducts
Slab Grade
f'Forms
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
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Undergrou rl F!-
Final
PLUMBING APPROVALS
round Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
F1^-;
_
_
Waste Lines
Water Pipinglumb'n
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
! !!!
Gas Test
Appliances
Final
d��
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)