9904-032 (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 ii . Date
6 5; 105, /00
Date 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:
( ) 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 70.44, 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. -
4 1 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. !Ay workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
f= M)
(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,
shall not employ any person in any manner so as to become subject ect to the
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workers' compensation laws of California, and agree th4toif'l should become
subject to the workers' compensation provisions of,Se-dion 3700 of the Labor
-Code, I shall forthwith comply with those provisions.
DA: * Y/ 6/ ``9j Applicant— , 2e� --I<—
V r -
Warning: Failure to secure Work'grs"Co4sationcoverage is unlawful and
shall subject an employerto criminal penalties and civil fines
s up to $100,000, in
addition to the cost of compensation, . ipensation, 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 pursuanfto
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 160 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
;71;1 .
theeabove-mentioned property for inspe ion Arposes..
V'Signature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
6XTEVALUATION
4,16199 LOT TRACT
JOB SITE — APN
ADDRESS 5.5-487SOUTHEMN MLLS
OWNER CONTRACTOR DESIGNER ENGINEER
ro. LVI
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C. At, I F 0 U'0." I A P' 0101 L S & J� A S
WO F,'CHAP.kA1q AVE -SW 100 774-725 j0N.11' DRIVE,#A
CA 92886 PALM DESERY CA 02260
(760)340-90W CRL# 355
USE OF PERMIT
T1100LA19NOR, SPA.
PiXA.JSPA,0N!Lv - ALAAMSAiARRIMS MU445T 13E IN PLACE A.
POCYL AND; -3R a -Pik 15,300.00 LS
FSTIRVIATTIU) MST. OF' CUMMIRUCTION
PERMIT FEESVMMARY
'PLAN CHEC,% 1',EH 101AM-439-318
cnmsmRumbwt FEE 101 -W-41840 WIJ)o
N11 CII'AMCAL M.7 - POOL 101-000-4-411-000 M00
ELF/01 FEE -- 13'00L. 101-000420dM $430)
RLU1V BIN0 FEE -,POOL 101X000-41"00 527.00
StJ[1340'AJ, CONS N -AND PLA 3HECK $1378, 15
MMMQ NC
Lf . 1YRE-PAIDFUS
WFAL PERIMITFEI;S 1111TE NOW 1 SON.15
REG!5
DATE BYje'DATE FINALED I INSPECTOR
I
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
POOLS - SPAS
Steel
Set Backs
Electric Bond 77 1-717
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Under dund.Pibg. 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
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: