9910-009 (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
,1'iofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
B C53
/atie\,��'°//>% Signature of Contractor ���' C�'�`�✓
-OWNER-BUILDER DECLARATION �.
I hereby affirm under penalty of perjury that 1 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.Clfor this reason
Date /J////% Signature of Owner/2' ,<sf-ilsc-
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 tl4e Labor Code, for'th_e
performance of the work for which this permit is issued.
(y) 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 a c^ 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
C,a'6e, 1 shall forthwith comply with,those provisions.
Wate: .�`7/£,''Y 3� Applicant
Warning: Failure to secure Workers' Compensation coverage is. unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost ofcompensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject' to the. conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person,at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees:
2. Any permit'issued.as a result of this application becomes null and void if
work is, not commenced within 180 days.from date of,issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct.,1'agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon .
the above mentioned property for inspection purposes.
4Signature (Owner/Agent) irp_,t`a`.iL_� G+,✓�a!'Date 'f
PERMIT #
BUILDING PERMIT
DATE ,983 in"VALUATION 5 i� LOT , I TRACT
JOB SITE
ADDRESS 79-517 '1'$)RWO DRIVE
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TP
Put;;.r�FECT PC, .t h y G��lLr,7viT�:4J�wia�CV
718.615 NAPLES DRI VE
P.0. f3OY 1524
LA. QUTN'"CA CA. 9212153
PALM :.'DESERT -CA1 wzz f
(7f�� A98 chi:# . '7S
USE OF PERMIT
-2-'t'il:1L ANDAA SAA
POOL tAba'L4iilR SFA E.rW100 Lei
1rEiW09.]..N. FRE W14J1�1'+ AR
.
PLAN C HL,*CK JVEE 101 -OW -439-319
M,NSTRUC,f TON 003F
AMECRA WAL UZE — x4OCA,
PLIMIrNG FEE-- - Pi)OL tr3l Aii'� 41�,Q1� ��7.Ek�
SUB-TMAL fX1NZ'11, R W7!0N ANT)PTA,r�Ifrc
$349.45
' ESS i -VI 11) FEES
.11�.V4s
RECEIPT
DATE
BYDATE
FINA LED
INSPECTOR
`W.
INSPECTION RECORD
ie
OPERATION
DATE 1
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel j
Combustion Air
Roof Deck i
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation ?
Condensate Lines
Party Wall Firewall _
Exterior Lath i
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Electric Bond
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
Sewer Connection
Pool'Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
l2-�ja
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)
M
A'RE-INSPECTION FEE Of $30
WILL BE CHARGED IF THE APPROVED �
PLANS AND 10B CARD'ARE NOT ON
THE SITE 'FOR A SCHEDULED
INSPECTION. •.
• NO EXCEPTIONSI
hiLff F.F. .117.50 N'
20, PLAN 4A A
100.00
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
'} APPROVED
` FOR CONSTRUCTION , 4�
;r DATE l BY s At.E
& A S S U C I A T ES
BELLA• VI -STA PHASE 5
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