9904-240 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N LU Professionals Code, and my License is in full forindact-.O 5 M License# Lic. ClassExp. Date
t; LU S£.99 C53 11/30/20(
Zr— Date Signature of Contracto
Z0.0 _
J V C> OWNER -BUILDER DECLJRATION
lV W r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ d. License Law for the following reason:
Z_ ( ) 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).
C'`) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
CL Q WORKER'S COMPENSATION DECLARATION
p 1 hereby affirm under penalty of perjury one of the following declarations:
Lo H cc
p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
Om _ Q pe rmance of the work for which this permit is issued.
Q U I have and will maintain workers' compensation insurance, as required by
ection 3700 of the Labor Code, for the performance of the work for which this
rn H permit'is issued. My workers' compensation insurance carrier & policy no. are:
t Z Carrier Policy No.
cr
g (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 manrier so as to become subject to the
workers' compensation laws of Califorflira, and agree that if I should become
subject/to he v orkers' compensation provisions of Section 3700 of the Labor
Eode, 11611 a11forth/I t comply with those prr "vi"S10 s.
Date: '? Applicant
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.
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 appl�tion and state that the above information is
• correct. I agree to comply wi : all City, and State laws relating to the building
construction, and herelayyutliorize representatives of this City to enter upon
the above-mentioned property' f4- inspection purposes.
nSignature (Owner/Agent) Date
BUILDING PERMIT PERM "44
240
DATEVALUATION $18.0N.00 LOT TRACT
5"
. /3 9?
JOB SITE
if
ADDRESS 74-840 Vii Aitii'1EL �
APN - -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
NMR. Oil: MRS. C? OONNEI..f.. -
FAA11LY POOLS (_',0N MILIM•ION
78-940 VIA CARMEL
53.300.tAVENIDJA RAAIlltl Z
LA QUIN4'A CA 92253
IA QUINTA CA 92253
(760)'W -M,55 CAIN 2803
USE OF PERMIT
P001. ANiuOR S.PA
€ 0GU ?A..,V,AItM3i 1..tARWIMS SUALL BE iiv AT PRE-PLA811-R.
1NtilaLit. C.If~>Ai.
TIWL A14'13;OR 'SMA 1$,(100.00 L3
W4111%V%IE0 i') S T Oar CONSTItVC 101V
1S.OI3 M111
€`IERMIT VEX StAINIARV
PL4N L"i-16L'K. l%1rT t01 -OW -439-318 S 1`.?:185
('Y)NMlICTION f»f; 401-fl(?Il-41R-W) III 34Utt
i4W01t'AN(CAL 1'EW •-lei: 101-000-421-000 S:1 0l1
ELECMICAL FTiF r-e,VOXX 10i -000-420-M �e 345.00
I-OLL Ml.•tlls I KA3 -- KKA i{I I.-0(00-41.9•-000 $2700
MAY 13 1999
(�V,'1 °gyl;1�11#'
�U
W7Rs
LESS 'II'd.-PAlD FT!ES
$0.00
TMAL.PFItMIT I+'F.RSI'' Ulk, NOW
S407.0
S.T.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
t 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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
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
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: