9909-071 (RPL)H '
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chajf'er 9 (commencing with Section 7000) of Division 3 of the,Businese' nd
Professionals Code, and my License is in full force and effect.
License # Lia Class Exp. Daae J!
10
ate Signature of Contractor 101,
OWNER -BUILDER DECLARATION—
I hereby affirm under penalty of perjury that I am exempt from the Contrhetor'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).
O 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
performance 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:
Cartier Policy No.
RUN, D n -1 .
(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 wl)Q, this ermit is issued,
I shall not employ any person in any manner\so as to co a subject to the
workers" compensation laws of California, and agree: t 't lishould become
su ct to the workers' compensation proVi ions of ' io J700 of the Labor
ede _' I f�!ith comply with thosisio,
a ' f
te: a i+ Applicant.•- �..�
Warning: Failure to`sequre Workers' Compensation coverage I � unlawful and
Shall subject an employer t6*criniinai-penalties and�civil fines up tW$100,000, in
addition to the cost of compensation, damages -as provided for in Section 3706
of the Labor Code, interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work, is performed under or pursuantto
any permit issued as a result of this appiicaton agrees to,.& shall, indemnify
& hold harmless the City of La Quints, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application,:and state that the above information is
correct. I .agree to cornplywith all City, and State' la s relating to the building
construction, and -hereby -authorize reprogentatives�this City to enter upon
the above-mentio`hed/property ter inspectibh4purpotes. r
'16/ignature (Owner/Agent) ;Gr t- :r
``� -- Date
BUILDING PERMIT PERMI6,
DATE mi rm"VALUATION si%,S)f'hwo LOT TRACT
JOB SITE S 4<<-'I44? 01.411B.I.lia'. ir.�.�`ME,
ADDRESS
APN _
OWNER
CONTRACTOR / DESIGNER / ENGINEER
c1e.lU A R.M-*.ze.r,rAmss:
..4_.1 �aa•�i R t�(t t� :y�c ,r t sl��:
45140 DEME. DR
73960 I-I4GI.13rJAY .! I t -
LA.(?_U1N"1't1 ("*A. u`?'253
f'AT:M NiS1sl f CA 9 25549,
41761,�3110_25F$ CIRL4 310.11
USE OF PERMIT
B7_ OL AN.l_+100. SPI
POOL & WA �. 4L Y - . LAKVtM6af"i1dEFki 813ti;i.%. BE 1N PLACE FIB
POOL f11Vr3. A.;;R SPA
ro WV v ;'C34i1'0nl' iviTrb'.►.►� i �ibr
x'i,►:.,l�°3
PLAN i°ttECK FEE Yi)'s 1K
470N'�t'5l3I7(•FfONFFF tllt-tl<3(1•=ttR%iN? tS�,frf!
ftifT;C 1A74C A1, Yt Y; ., POOL 101-4011423 4100
t)f..L?�].i3fE�t'r F't-� — f'!.!I"�3d !Ot-fii?1)-•'I1'�-t1rJ4 �;t%.tn)
��lk,•`tY1X.-i,f°ty�;�;litt)f")'�f�hP �.NT>r�4,_ 7vft'F3hC'}'+',
1391, 04)
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1393.0
RECEIPT
DATE
BV
DATE FINALED
INSPECTOR
0
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHAHCAL, 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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS a SPAS
BL,OCKWALL APPROVALS
Steel
Set Hacks
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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
3_
Gas Test
Appliances
Final
6 At -
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)
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
.NO EXCEPTIONS!
m�
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE t BY j�_
NOTES:
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