9701-120 (RPL)LICENSED CONTRACTOR DECLARATION
to T-I;hereby affirm under penalty of perjury that I am licensed'under provisidns'of
-Chapter 9 (commencing with Section .700b) of Division, 3'of the Business and
C\I co Professionals Cod67, and my License is in full force and effect.
C—:) Z) co License# Lic. Class Exp! Date
r . W
.106 L
Z0 rr /ateSignature of Contracto
77
CD
J 0 CD OWNER -BUILDER DECLARATION
LLI Lij I hereby affirm under penalty of perjury that I am exempt from the
CL License Law for the following .. ng 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 ($ec. 7044, EUSiness - Professionals
Code):
cOI am exempt under Section B&P.C.'fo,r this reason
N. I
0 N Date -Signature of Owner
.
0)
WORKER'S COMPENSATION DECLARATION'
CL
Z
C[ I hereby affirm under penalty'of perjury one of the following declarations:
Lo <
i Z 0 have and will maintain a certificate of consent to self -insure for workers'
X w � Compensation, as provided for' by Section 3700 of the Labor Code, for the
:0 _J performance of the work f6r which this permit is issued.
< C)I have and will maintain workers' compensation insurance, as required by
0 0 < Section ction 3700 of the Labor Code, for the performance of the work for which this
aU-) permit is issued. My workers' compensation insurance carrier &'piolicy no. are:
0)
-,t Z Cartier Policy No.
0, 01"ATE FUND
< (This section need not be completed if the permit valuation isfor $100.00 or less).
I certify that in the performance of thWwoik for which,this permit is issued,
I shall not employ any perso n in any manner ner so,a:s to,become subject to the
workers' compensation laws of Califo rnia, and agreeAhat if I should become'
subject t6 the workers' compensation provisions -'of Section 3�00 of the Labor
S I / ,
Code, I shall forthwith comply with th6e;6"rq7iWnsY
/Date: Applicant
VWW"
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 I his
application.
1. Each person upon whose behalf thig application is made & each person at"
whose, request and for whose benefit work is performed under or pursynt to I
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,folr 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 Ail 'City, anOState laws relating to the building
construction, and i
hereby authorize representatives of this City to enter upon
* authorize , . Jo
the above-mentioned property I for inspection purposes.
Signature (Owner/Agent) &' q! 11 111 - oil
PERMIT#, CONTROL#,",
-BUILDING PERMIT V,
9701-120 r% 0%
DATE VALUATION • LOT, TRACT-,
JOB SITE
APN
ADDRESS _'507.5 WNGRA) MOT
.1
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CAL NUVMOLS & SPA,
5,1 1� WINGED F001'
74-725 JONI DkIVE, 111.
i,A QUIWA, C.A. 97251
PALM DESERT C -A 972(0
t'fal9Pf3N!iiNJ-Isrs
USE OF PERMIT
F, . f_1;'Ctf1rI1kUK
POOL ANrXOR VAL 4,,000.00 Lo
W1111,11ATED ("40.311 or C-0,11NISTRUC N
to .00
PfUlMrf 41Elf—SUMMARV.
.4et,
PLAN CRECK. 141' "095
A A0
rl,hC[10CALFtfl 14:*L' :'Joi,1001 4,2fl-000 $4
PM, V001,
!KI-TUYAl rT1FCK
f
otrr s W.C."NOW
�r-Ok:,IF
RECEIPT %.?. '
I DATE
BY
DAT E FINALED
INSPECTOR
t
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
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 i
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
' mp. Use of Power
t '
.ty Notice (Perm)
COMMENTS: