0003-145 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
_Chanter 9 (commencing with Section 7000) of Division 3 of the Business and
ProirSssionals Code, and my License is in full force and effect.
License # Lic. Class.-- Exp"'Date
69{itv+-5/f/i1 Glu 3U%'261t
da 'e_ YSignatu� of Contracto 'f`'' 7
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
pe orfi5'ance of the work for which this permit is issued.
S&1 -have and will maintain workers' compensation insurance, as required by
ion 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.
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rvnn
i1Va?. V�1iYanX/AXA l/VV4.. ••tJt.
(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 t�o.•become'subject to the
workers' compensation laws of California, %d agree tha jiff should become
subject to the workers' compensation provisions/of Section 3700 of the Labo,[,
Code, shall-fotthwith'comply>with�ose provisions
'✓Date:._5 -/I' U�APl ljcant �ttav <-'"
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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.
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
thre above-mentioned pro erjty/-for inspection spe�ction purpgses.
Signature (:Ow er/Agent`°) �9 " Date' �l1
PERMIT PERMI4101)�445
j�ABUILDING
DATE l� 7 "w✓ VALUATION�fi'�{}it.I�{I LOT TRACT
JOB SIfE
ADDRESS 6,--)85 SPY d,au#.IMHULL
APN
OWNER
CONTRACTOR / DESIGNER /ENGINEER
,R I'"), is2]CIISp 111C.4
1V^ MIC.
P.0.4ol1C8i0
1423:# E. %73vMERSITY DRIVE
LA QV1'NTA CA 922.53
P1109NM AZ 85034
16{321757-l65ti Ca -1.1 49.90
USE OF PERMIT
POOL ANDIOR SPA.
P0_47L & SPA ONLY- ALtV�C�lbMGi%RR.AER i SiW,L K IN PLACE AT
R64 "LAM'EK !NSi E "1ION
VALUATION I VOW 0.OV LS
.wI tTITI i.•AsITED �i.os" or'' a4..+'+UNIT ieUCTITIi"N'
a VAINI .01i
P.tr'RA11T 1<4'Y+..I!.;3£rMAURY
PLAN t,MEXX J^ kig $76.05
r, ?wwr„rar f(TrION 1014111}-4194M 5117 01
Ju f
PvlGCEiir�` I CAL TM n -POO!, 101-4)00-11"I-fl00 4.114.00
FILIVi` i AL FU -- BOOL 1.01-(W-420-000 Sfg.f3i1
PL UNI..BINO Eliz° --1 L 101.-1)0()-419-000 27.tN1
l li3 "IY7 'e�.i. (" _)Nf-S 9I_X TfQN AN}'I
i.�.��' ��Li''.-�s'a.r�i I''��:
t Ti ;0•`130
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'$O AI., P.ERNIFF YKE.S OUP, NOW
$289.05
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RECEIPT
DATE
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
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS-SPAS
. S
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
O
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: