0201-113 (RPL)LICENSED CONTRACTOR -DECLARATION r
a I hereby affirm under penalty of perjury that] am`licensed under provisions of V
F—.- Chapter 9 (commencing with Section 7000)'of Divisiv) 3 of the Business and
N WProfessionals Code, and my License is in full ,force and effect.
0 =) M License # Lic. Class t \ Exp. Date
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LLl f� t^ -i l e C-36 MO� C534
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Z r` )ate. {�✓ "% Signature of Contractor
I``, F-�. C OWNER -BUILDER DECLARATION
Lulaui: I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) I, as owner�of the property, or my employees with wages as their sole
.. compensation,•will°doIthe 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
LO
�! Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( )• 1 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. .
�,V) 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. My workers' compensation insurance carrier & policy no. are:.
Carrier. Policy No.
STAT FUND Aad-�t7 AJ$
(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'provisiorisr
Date:` l:. ?,/. -. �. Applicant—Y. q" . 2 _ 4.
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 oripursuant 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 employee'
2. Any permit issued as a result of this application becomes null and void
work .is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permitto 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 property for Inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT
DATE VALUATION LOT 0:1I•`1.. TRACT
JOB SITE
APN
ADDRESS
54-371. S07MIUM.MIZ
OWNER
CONTRACTOR/DESIGNER/ENGINEER
54-37 j
a4. oi`.'}.'l y, FIVd:elLM DMI BOY,
Z.A � 111ITA CA 92 253
PAKA�, M)RNGS CA 92262
USE OF PERMIT
00 01, jqlb/ak 21
Swita3kyi'iNO P°.DC)L IUP,tiC�DItL )?I!r%A,'PPR(:)VLPD PLANS, I 0A..fib'PROVAL
POOL A14 W, OPv SPA 31,000.00 1.15
C70'.NS'CRUir`('.ION ME 101 -1000 -418 -ow $201.00
EL•I!:CTRIC-AL FTf,E, -• POOL 101.0U0-47, 3-000 $45.0
P1.1JU SX.Nt',:f I+IM POOL 101-000.419-000 07.00
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SAN 14 202 f..
RECEIeT
DATE .;
BYDATEFINALED•
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
h
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
62
dQ�t%U
Gas Piping
Gas Test
Appliances
Final
b2
�(,L LYLD
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:
O~� _
n
r
EMO\/E 550
No
MAIN
ONGRETE
G®J
LED67ER ST®NF= - Tn P�1= I � � �
.EGTED
SAF
DRAINAGE
CITY OF LA QUINTA
BUILDING & SAFETY DEPT'
�. ROVED
E L EVAT 10 NI 1 /2 = 1 _O
APPROVED
FOR CONSTsucTiON
07, ey
DATE
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