0302-118 (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
Dates Signature of. Contractor.
M
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
J•
it 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.
( ) 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:.
Carrier EXEMPT Policy No.
(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 provisions.
Date: Applicant��2* 1-'1 �/'JA
)e _ ,.. -
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 compensatio,nf7damages 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
the above-mentioned property for inspection purposes.
"14041ASignature (Owner/Agent Date
BUILDING PERMIT PcRN11T# `
DATE VALUATION 0r LOT TRACT
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JOB SITE
ADDRESS o-i„�}Q13 y{>`CI%XeY
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VItVCND 110dLI IND 6R181
1.ok QVINTA CA 92253
;ALTA DMERT C11A 92211
? O� iifi-SS CIZ3:r<O 3158
USE OF PEnR1MIT��LL����`` .
POC3I.t'Sf•A. A-LA:;,1XS18APJUI`•.R SHALL BF, IN PLACE A,T ,PH,
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POOL MID= �r A A0000DOL
CITY FLA QUINTA
FIN NCE DEPT.
1 {
i' AJ4 C1' WK FEE 101 -0004239-3118 VARM
CONSTRUCTION ", 101.000-418-000 $3,'t6iso
-- POOL 1.01.0/00-4,21-U�Q�0 $$24.00
Iti s, Y�c
NELECTRICAL
f1�Nt�p'.Ey4.1���+1E1E
101-000-420-000
ELECTRICAL M2 xa POOL 101-0 0-4 0-000 $45.00
1'LI..tMBINOT �19-SPOOL 101-000.419.000 S 40
.G�+Nf��d�✓�9 ��J1 8• A3R5f� ei���r �CBTd�1 M� n6vu�
RECEIPT
DATE {j �„'eY�=�•,-*,�
DAT F L D
INSPE O
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
POOLS -SPAS
BLOCKWALL APPROVALS
steel
/�
Set Backs
Electric Bond
y7�
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
3
I
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
3
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
02/13/03 05:19pm P. 009
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P.B.
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02/13/03 0S:19pm P. 004
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02/19/03 0S:19pm P. 00S
SIACK1=D STONE WATERFEATUE AT +24"
WI T}F STONE GAP AND FACE
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CITY OF LA O.UINTA SUB -CONTRACTOR LIST
108 ADDRESS PERMIT NUM ER OWNER BUILDER_..
'his form an the job with the Bulilding Inspection Card at ON tlmea In a consotcunue place. Only personsappearing on thio list or their employees are authorized to worj
rn this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Fa will re It In a at page of work andlor the voidance
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Trade I Ctasslflation=WwW1tate
GorNneveor'a Livorno
lon. License Number
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Cartier Name
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License Number ENO. Date
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PLUMBING (C-361
LATH. PLASM I0-36)
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DRYWALL (C -B)
HVAC IC -201
9.EGMAL IC -10)
ROOFING IC -381:
SHEET METAL (0.431 .
FLOORING IC -16)
4LA21NG 1C-171
lNBULATION I0-21
AWAGE CUP. (C-424
PAINTING (C-881
CERAWC TLE (0.34)
CABINETS 1")
FENCING IC -18)
LANDSCAPING IC -271
POOL (C-63)