9809-111 (RPL)74
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9.4 mencing with Section 7000) of Division 3 of the Business and
ProfWionals-code, and my License is in full force ,and -effect.
License # Lic. Class'` Exp: Date
$9()645 �i00
Date, Signature of Contractor
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.
I have and will maintain workers' compensation insurance, as required by
Se tion 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.
STATE FUND Policy
Zi'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 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
ode, 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 on his`;,y
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
PERMITCONTROL#
BUILDING PERMIT
DATE VALUATION S12,t1i)0.00 LOT TRACT 8215
JOB SITEADDRESS 50-217 1 1101 i L S IME.' ' APN �
CONTRACTOR/DESIGNER/ENGINEER
WTHOINI S 111 Jul- INVPs-riwl?Imm", mc.
PO BOX 810 1425 E. UNlNTRSMY ORMI
LA (XIN1'A CA 92253 PROF NICK A% t Sou -
(602)757 -1656 MA 4")
USE OF PERMIT
POOL, AND/OR PA
PO:%J..iSPA, A
INSPLXI i' ON:
SWUL.11EWN17
SPOOL ANDDIO..R .SPA - 12,0(*.001.S
1t.S.1�11MUM C08T C08OF C:O°viT.%CUCTb'OIN
41./3'
rON 1'MM'1'10N $13500
MEC1l'FIIIKA1 t+Effi--- POOL 101-000-421-000
E;EM R➢.CAL FEE, -- POOL 101-000-420-000 $45.00
as Ai-I11}INO FEE _- .I POOL 101-000-419.,000 $27.W
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,'';f ^s
work is not commenced within 180 days from date of issuance of such—'T r
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permit, or cessation of work for 180 days will subject permit to cancellation. t ,�•
I certify that I have read this application'and `state that'the above information is
correct. I agree to comply with a I City,•and State laws relating to the building
construction, and hereby,authorize,rep�esentatives`of this City to enter upon
RECEIPT
0OTA?., _CY)NIM [XTION ANL PLAN CHECK
t LESS, PRE -PAID FEES
SES
E^, BY DATE FINALED INSPECTOR
�n 2tt��)it�0i�
$??S.r`
$0.00
$.5..t.75
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8`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 APPROVALS .
steel
. 2—
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 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
c.
t
Final
Utility Notice (Perm)
11.