Loading...
0402-253 (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 Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that.1 am exempt from the Contractor's License Law for the following reason: ,,(A,Y 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 t% ,) q Signature of Owner -19 hf A1,1 —t 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 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 fo hwith comply with those provisions. /9 f (,1 Date: ' Applicant /' + � A . _1J ? i i •. 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 persQn at whose request and for whose benefit work is performed under or purs to any permit issued as a result of this applicaton agrees to, & shall, ind & hold harmless the City of La Quinta, its officers, agents and empl 2. Any permit issued as a result of this application becomes null and tuh work is not commenced within. 180 days from date of issuance opermit, or cessation of work for 180 days will subject permit to cance I certify that I have read this application and state that the above inform ion is C correct. I agree to comply with all City, and State laws relating to the b construction, and hereby authorize representatives of this City to, -enter upon the above-mentioned property for inspection purposes. � f ;,/Signature (Owner/Agent) PERMIT PERMIT# .BUILDING DATE - t VALUATION LOT 0402.-,,,%A'J TRACT JOB SITE APN ADDRESS {9 475-9/7«9 LA .REVINA couYza - OWNER CONTRACTOR / DESIGNER / EN (NEER MIC HAM 01 W]?] 0Wd R - BUILID R. 45.905I AI'EINACOxJRT , .LA;. QUINTA CA 92253 USE OF PERMIT PO OL !MIS R IBM P'iJWSPA, 12 LK, 51 BLOCK WALL, CITY STANDARD. t d1UAItMS,'AARRIERS, SHALL BE IN FL C AT 1o4'reT ow, S FT. WALL 12.00 JIF POOL .A.NDIOR SPA :29;741,00 LS US'i�7'o 1. MD COST We i i?MIRIU .ON ,VI.r �W' SUAWAR ' PLAN CHBCK FL -19 l �I �QpiriG'I�3»�l R gi�9.15 CONSTRUCTION RUCTION YZE. MCCkI,OICAI.s FEE — POOL 101.000.421-000 MOO PLLrC:7'Rif✓.'#.; Ptr7—POOL 101-000-420-000 $4::.00 PLUMOINO iR --POOL 101.000.419.000 $27,00 0i VOTAL C(aNMUCM, 011 AN31i PZ" CHWK "96.I 5 L:z1 LESS P`l ii PAID M, 3 I O.G�Ce EB 2 5 2004 TCft l., -V: &` Xr 9 ME NOW TY OF LA QUINTA FINANCE DEPT. RECEIPT DATE BY r DATE FINALED 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 Final � Final BLOCKWALL APPROVALS POOLS - SPAS Steel 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 O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer.Corpection EncapsulationIN 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: f r [fie, -e La G-oo,�Q. v L CITY CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROuED FOR CONSTRCTION 3 r -r Av� At �0l; CITY OF LA QUINTA SUB -CONTRACTOR LIST JOB ADDRESS L15905 PERMIT NUMBER OqO.;2 OWNER BUILDER Q144AX4't-' This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearin g this list or their employees are authorized to work of building permit. For each applicable trade, all information requested below must be completed by applicant. -un File- is not an acceptaDie response. X.. ....... ....... ......... t`tade4 al ..................... ............... .......... ........ ............ :XX ..... ......... . ..... W k a i. .... ........ ........... .. ...... . ................. ...... .. ........... .. ... ........... .. .......... ..... . ...... x.­':X::x'.'.'.'.'.'.'.' .. ........ .......... . ...... ... ....... X ...... Company Name Classification (e.g. A, B, C-8) License Number (xxxxxx) Exp. I?ate (xx/xx/xx) Carrier Name .(e.g, State Fund, CalComp) Policy Number (Format Varies) Exp. Date (Xxixx/xx) License Number (xxxx) Up. Date (xx/xx/xx) . .... ... x x: .... ....... foot? 4 - ......... . _9 ............ .......... ::: 0_ X., . ....ii'.... . : - X. - .1 ** ' '.'ONM f r� -1-e- C -S3 s4 ,+e- r�,tjd Li .......... ........ ..... .... . ... ........ ........ ......... . ... ........ IN ... ........ A AABI ............. ........................................... .. . ......... ......... 'A. . . . . ........ . ........ S I 7 -5 9 5-3 •0 3 4j Z. ............ Koe r L3 el -03- _10vwZto 1 7.3 q .31 Mt R.-Y.W.'AL.. . ........ ............. - .. .. ...... ... ......... .... ........ A C_ ML a1 8 ...........