9811-087 (RPL)LICENSED CONTRACTOR DECLARATION
U) r herebyffir
am under penalty of perjury that I am licensed under provisions of
1` Y hapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W i Professionals Code, and my License is in full force and'effect. .
O ,� ch License # Lic. Class Exp. Date
57,4127 A f 6x31199
o Z r` /ate 1417Signature of Contractor ll
(� 0]
J U C:) OWNER -BUILDER DECLARATION
W UJ
rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 1, 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).
c'`) ()' I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
Orn
j d Q WORKER'S COMPENSATION DECLARATION
vo 2 Z I hereby affirm under penalty of perjury one of the following declarations:
U-) O () 1 have and will maintain a certificate of consent to self -insure for workers'
-X w L: compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
C0 Q U 1 ( I have and will maintain workers' compensation insurance, as required by
U
O Q Se�on 3700 of the Labor Code, for the performance of the work for which this
fi rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
cb Z)
r` O . • ..
S7'rt'f'F; NITNQ ±^ tf PIN). A8
J (This section need not be completed if the permit valuation'is or $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
de, I shall forthwith comply withl*'thlose provisi SV'rat.
e: %// !. Y` Applicant��
Warning: Failure to secure Workers' Compefisation 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 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. l"agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
/thehove-mentioned property for inspection lu-o
uroses.
ature (Owner/Agent) r�;" Date /
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ijfi#_�� TRACT
1%13-550.0111, 7S
JOB SITE
APN
ADDRESS
79-115 MANE DRWE
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
t
JEHPCl% vi�t'.�li .RS
STEVE E CilaSt f t�t�h`S�fs , fC"3"irsN
t 9-1I D. iii i�R�'v�
1301 i i.lJtj7V!`i'l�" CLUB ute.., SUMZ114
LAi;��;lI IA CA 92253
PALM DESERT CA. 92260
(74u)1W4032 CIM 1044
USE OF PERMIT
1?OL�{11,./SPN F\LAWIIiIS1M �if ETkg SHAD. BE, IN AT PRX.N. t 9R.
1t�fS•�,����Lt�fd
POOL ND.k)k SPA. M550.00 LS
PLAN CHECK 'ME 101-000-439-3 48 S t 28,70
('c7N t i t.l ,'tctN 01M, Ii) t,-•f)tl0-418-W, S198,00
Iv C14:A2ACAi,rrx.--T'<Xa.' I01-000-421-000 $2=f.00
ai,:cTRICAL 1,Tr -- POOL 10 -000420-000 $ i S, W
PLf_gVWfN0 M. P0011. 101-000. 419-000
SMB..'tY'"frt kI ON'FIROC;TION1 AmE.) Pt..A,*•J f"t:fVC, K.
$412.7n
LESS P;R -.PA T I7 .IF 1° ES
$0,00
a
.$422.70
RECEIPT
RECEIPT 7�T�
DATE
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Ak
Bond Beam
Approval to Cover
Equipment Location
Un
—Z,3 -
Underground Plbg. T
Final
PLUMBING APPROVALS
Gas Test
Electric Final
'
Waste Lines
Heater Final
.Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pan's
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
En psulation
p
Gas Piping
I
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke detectors
Temp. Use of. Power
Final
_Utility Notice (Perm)
COMMENTS: