0201-055 (RPL)IW
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
595751 X31179'F�/;�Q�C9�
/Date ^/n " cSignature of Contractor -''`'A IA, -A'"
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
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.
A(,ti)' 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:
Carriar Policv No.
MAT It FUND
(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 ,thoselprovisiono '
Date: 01- Applicant t -* .dd tr1 tela
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 applicatiomis made & each person at
whose request and for whose benefit work"is performed under or pursuant to
any permit issued as ak-result of this applicaton 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 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.
� I
Signature (Owner/Agent) Datef d r'3IT"
Y
BUILDING PERMIT PERMIT#
DATE d' 'moi VALUATION LOT =1_113M TRACT
sqoo
JOB SITE
APN
ADDRESS 51-9507�M1A'i�i"
AVE, MA,
_
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PAZ r:'.OIN91fiUCH0114 CO
PAZ +✓OXF- rRIMMON CO
52•995 d3WNWADA.AraENDOZA
52.995.14"VWlDA;fV1�:,fi�DOZA
I A (""CaNTA, C".41: 922:53
;I& %}`t'1WTA CA. 92253
USE OF PERMIT
PO -OT A1435. OR SPH.
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POO.T.&RA. AI.A.>1i.B S/8All.R.t1?RS SHAI,I, iii.=; IN PLACE AT PR9,1=`1A r.ZJ ►
ilv«1PiCC;'NON. POOL, RQUXP'PaIFrNT FENC I.,OSCIP.E NOT ro. 01.,CIDP ),
POO1, ANDJOR SPA 9tlOt .OQ LS
:I W r FIVE MARY
PI,M1A14 CHECK ME 101.000.4:19-318 3: IN
CURS"TidUC71M.1 FEE, 101-000-418-000 SIA8.00
WCHN010AL n, B -- 4 OOL 101.000.421-000 %X G01
J?Jl.9VT14CAL PEZ, -i, POOL 101 -000420'60.0
PLU?dii YNO na • Pool, 110-1-000-419-660 W.
JAN 14 ZOOZ U .
MYOF.LAOUNTA
@� mo
SuB.�-` MAL (';C"2oi'S:1'R.'iiC'`` -10k;f tam. PLS' C'. m
3+77 . irc�
IisS` P'FE*PA1D F.1
:T0100
RECEIPT
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
2. r_ o 2—
Set
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
2 - — U2A
G -,O<
Underground Plbg. Test
✓j
Final
Gas Piping
11
PLUMBING APPROVALS
Gas
Electric Final
Waste Lines
Heater Final
Water, Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
_
_
Axe_�
_
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conc
Rough Wiring.
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacle
G.F.I..
_Temp' Use of Power
Final
COMMENTS: ` I
G'SU>CK WALL j.
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LA. QU 1 NTA, CA. 9225;
POOL I 3'x 18
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SM W1.rlEP.
1010'
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--LOCK WALL
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CITY OF LA QUINTA
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BUILDING & SAFETY DEPT.
j ,APPROVE®
FOR CONSTRUCTION
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DATE _�—! I -01 By
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