9604-039 (RPL)LICENSED CONTRACTOR DECLARATION
Cf) I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7.000) of Division 3 of the Business and
C0
C\1 W Professionals Code, and my License is in full force and effect.
p Ch License # Lic. Class Exp.
Date
Lo
1 r LLJ 55(2X, 2r,807
Z n Date
r--
U Signature of Contractor—e
CID 0
0 OWNER -BUILDER DECLARATION
UJ LIJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CD License Law for the following reason:
Z_ ( ) 1, as owner of the property, or my employees with wages as theirsole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project .(Sec. 7044, Business & Professionals
Code).
l plunder P
cr) aexe r Section B&P.0 fort is reason
LO
C\J Dat e Signature of Owner
0 N
0)
< WORKER'S COMPENSATION DECLARATION
CL
C) Z I hereby affirm under penalty of perjury one of the following declarations:
LO Cc -insure for workers'
– 0 1 have and will maintain a certificate of consent to self
X UJ compensation,* as provided for by Section 3700 of the Labor Code, for -the
0 J . < performance of the work for which this permit is issued.
_J
< C) I have and will maintain workers' compensation insurance, as required by
LO Section 3700 of the Labor Code, for the performance of the work for which this
0) permit isxi§,SQ1iRdJ, compensation insurance cACrJ6,r4'4(policy.no. are:
`11" z Carrier Policy No.
ob 0
C)
(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
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 onfiis--.
_,application. ' I ,
1. Each person upon whose behalf this application is made & each pe�Cson,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 informationlis
correct. I agree t City, and State `laws relating to the building
0 comply with
construction, and hereby autholle r6presentatives of this City to enter upon
the above-mentioned property!fo insp'e ion purposes.
SiI gnature (Owner/Anent) J Date
_-A
PERMIT# CONTROL#
BUILDING PERMIT "04-039 3081
DATE -4/1o/96 VALUATIONLOT TRACT
4';- 185 DFSE'k-f FOX
OWNER
KENDAME,
I.A QIJIWI,�A CA 92253
USE OF PERMIT
POOL ANI3 813A ONLY
APN '60440-031
CONTRACTOR I DESIGNER I ENGINEER
SIPIRISF KXXS
44028 ELKHO RN TR_
IRALfvl DESE-Xr C.A. 92260
ioiq)14(1-55-21 1 1. CK# lieu
LOSTI M A T E D C (IS T 0 V C 0 NS T R 1.1 CT; , 0 t 4'
VE,RM, AIM A R V
11. AN CHEM,"FEE
1OW100-439-318
$49,45
CONSTRU-7fION r-ET1
101. 4W419-000
$15211.0
NO HANK.!AL FEE — POOL
1Cj1-0WA121-(J00
10
fA,C-C.TR.(CA1, FT11 — K)OL-01X)_Q'04K)0
ptlumwmcm-w - Pool.
101-0co."419-Wo,
13,401M.K.)
SV'9�T9KkLC0K$M. Ly—CTION.AND PLANT CHECK, $118,45
1,11 -SS 1?RE4)A[0:FF.ES $0.00
PER N5 IT FE FS D IJ E NOW
APR 18 1996
-
RECEIPT' -15A—TE BY 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
POOLS - SPAS
BLOCKWALL APPROVAL'S
Steel
Set Backs
Electric Bond
OR
Footings
F
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric zool
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 Connection
Encapsulation
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)