0108-355 (RPL)LICENSED CONTRACTOR DECLARATION
1 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
Date `"'� �°%� Signature of Contractor
a rte" ' - f
"� OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 owher of the property, afn exclusively uunliaulirly will, liumised
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
Sa?ion 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.
i 'TX%T4y,R1'k' ."i'4 b41 fJd16
(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 3 00 of the Labor
Code, I shall forthwith comply with those provisions;
Date: 1" Applicant / J
f v,,
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 application is made & each person at
whose request and for whose benefit work is perform(sd 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. 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 or inspection purposes.. f
ff,* / s iA
Signature (Owner/Agent)• Dates
BUILDING PERMIT PERMT#
/
DATE( VALUATION LOT li3gQ TRACT
JOB SITE
APN'
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
q.:.D. 111118 UM' DRIV ZO, IXDI CK`
<M -La; :roTtNM rGou & aVAH (TOP IAM col
P. 01 DoX 1? 16
74725 JUNUMVENUITT, 40A
1A QUI;A TA CA 92253
17.F IM DEM717 CA 922603
Cdk+(i)340.9000 Csui 353
USE OF PERMIT
P001AR A. R1 AA':fl>'SMA ` MS SJ -411,1, HE IN PLACE A A PR&fTIA;w f;> R
Dr°''SPEC:'.e109, P001.AQUIPMES T PWOL09MR'• NOT D$1°:l,UM'D• v
POOL A1 WORBx''`A AMID, Do 1.9
ESMWKWID COVE` 10F C:OMMUC':Z'1U3RR
C0HS R 1!CTSO14.,FhZ1 101-000-418-000
MECIMNICAl.. PEI R P001, WI -000-A21-000 04.0
1111+,F'MAD10KM -- pC;tM r lbi,,000 41moo
rl::
SEP 0 6 2001
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RECEIPT
DATE %
BY
FI A D
INSPECTOR
�; Y� sw _ .,:., fl..•.-.,•+..�.• .°l:.p ~� �•.. ^ r.. ,Q. t✓'ti� {x ,:-sR ;1r:4,. 'i dress '°. r r•�' �:r.�',`.i' .,. i 't. °v' ..y.♦• t .�. Ir'., .#"+� wj, „ry' ..�i.,,,. „
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 APPROVALS:
steel
�.�-�. -
Set Backs
Electric Bond
�, C
Footings
Main Drain
Bond Beam
Approval to Cover .
Equipment Location. .
Underground, Electric
Underground Plbg. Test..
Final
Gas Piping
PLUMBING APPROVALSGas
Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
_
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Se+NX Lateral
Pool Cover
Sewer Connection
Encapsulation
ti n'Piping
Gas'iest
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)
1 a TjII[_