0308-156 (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 Exp. Date
. 656128 05.14 me 2. d2�
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:
( ) 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
pejrformance of the work for which this permit is issued.
r 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:
Carrier0,WJA SrATI Policy No. li46.616$-2 �
,t
(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 f the Labor
Code, I shall fo hwii h comply with thos PT
P'
Date: _J �'•.�idApplicant Ay
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. t'
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 cif
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
the above-mentioned property fopailillspection purposes
Signature (Owner/Agent)°' Date
rr
w ='. PERMIT #
B�... ,� ' ERMIT
��,�
-156
DATE VALUATION ��II g �/�fn �'p� LOT f TRACT
JOB SITE
ADDRESS 6�I� J�'iv, ry' pYVE
i�
APN
OWNER W.
CONTRACTOR / DESIGNER / EN 1NEER
L ANWOR MU - "MRS
(;AIFOR1~ M POt?1,.P &3,P11.8 fix- 3±l�'.i�N CQJ
90.481;lU17 F.R J A1TE
RhaA 00Av t % 54
I.,A QTTWTA Ca` % 9212-13
COAC107.,LA t"°A
92236
(760)396.9222
mo (Tom
USE OF PERMIT
'POGL AMIOR SPA
'IPA, Fel. EPI (496 AGA" .15 Lly. N O1. = WAU, CITY .
STANDARD .ALAitMSff ARTI44'. S SHALL BE W 1'L&CR AT PPX- PWTZP. ;
S FT. WA4L 19,00 •L'F
POOL Ai DI OR SPS I4,6 �f.Ob 15
XMK&TED COS OF C'O.il"'sc°3RRUC17ON
rKfLWY'�,3RY
PLM1 QHE—HIF, S11700
CONSTRUCTION PW 101-000-418- 000 $11�O:Clti
ME HAJNICAL F°?rrE -- POOL, -101-a=-421-000 $aX00
HIAZTRIC, a -L TOKE - POOL $45.00
P1.UMB100 PEE --POOL'.' , 101-000-419-000 87.00
}
MBS C3`,'CAL C0Wf.9V6n1, .0.1,T. ;kLW CMX
$393.00
U09 P.Rt-PAID FEW
$0.00
IDFFMAM
FF DUEJO
-00
AUG 18 :1003
CITY OFLA QUINTA
FINANCE DEPT.
RECEIPT
DATE it
BY � �
DECTOR
VIV v n
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
OX 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
Set Backs u
POOLS - SPAS
steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS �
Gas rest
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
Sas Test
lopliances
-
Final
Final -
Utilig 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: