9703-007 (RPL)LICENSED CONTRACTOR DECLARATION '
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chaptpr.9 (c ymencing with Section 7000) of Divisioh 3 of the Business and
Professionals Code, and my License Is in full force and effect. I�,`�
LLic. Class
License # l/ i • �• ,� Exp Date
6,556 129
w� / >` d J1 f
Date Signature of Contractor r 1" t
;•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).'.
as owner of the'property; am' exclusively contracting with licensed
Contractors to construct the project (Seca 70441: Business & Professionals
O 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.
Se( ) I have and will maintain workers' compensation insurance, as required by
tion 3700 of the Labor Code, for the performance bf the, work for which -this
permit is issued: My workers' compensation insurance carrier & policy •no. are:
Carrier +- Policy NO:'
ki;Cts+`m!'046-97-W010
(This section need not be completed if the permit valuation is for/$100.00, or less).
O I certify that in the performance of the wor0or which this permit is issued,
I shall not employ any person in any manner/soy as to become subject to the
workers' compensation laws of California, •andVagree 41ia't .if. I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I s. all forthwith comply with those p`roviSions� °
Date:''T� APphcant18r7I/✓44;y> •:
Warning: Failure to secure Workers' Compensation coverage is unlawfuLand
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 rest(ictions set forth on his
application. t
1. Each -person upon whose behalf this application is made & each pe'rso6 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 Ouinta, 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 il,86 days will subject permit io'cancellation.
I certify that I have read this application and statd that the above information is
correct. I agree to comply with' All. City,rfarad State laws. relating J6 the building
t r
construction, and hereby authorize representatives of this, City to enter,upon
the'above-mentioned propert�y1o'r inspection �pfu�rppo-s-ess'`�;,
Si nature Owner/A'
en t Date
PERMIT# �' CONTE_1L# `
BUILDING_ PERMIT• , r J"1i;1:�407 459
DATE:,�1�� VALUATION' �_,l,i�Q�a�a��i; LOT- TRACTJOB
SITE
ADDRESS %:l%CiEOFTAPNOOT.
OWNER CONTRACTOR / DESIGNER / ENGINEER
•.d �GY.i� 1Y'. ., _ S. ,t .. .. IPM 'TIA P00U,PAS
lie�I
547'x:5 41+'liYdm) ;�C: dr .' ' 74-75 JONI DRIVE, 4 t�
-
1:11 t Lll'N"1';� t A 2253 P.:�i,,111t DESI'�.T CA. 92266
3-55
USE OF PERMIT
1't `XX
POOL ANO SPA ONLY
f100L AND101Z SPA- 0.000.00 LS
.. 11,��. 1lli�l�i LililV./�•I' i/i�' �t 1.�5`6�..L i\Yd i.Yl ��i\T. �Yp1y�y��
.�.._ai��4l�9.0>)
$b8'r��.i�.l�.�:$ „it•gls.4)i ��A'A:I�,NItt�T .. . '
'". -
'i;�t.AN
9t)'d; 11ti11=�1:�-t){.117 �-.'$g144�ORR
,�. -X-
,I£100(".—t-003
L�i�(�%3A1�1�;�a.1"�E.r1O 3•, t I 100 (P"., - 1 -000
f f,..rsc;'''l�t3E:A�, :1 f,�lJ •�•- J?r�fiL . ,10�-Ot;t�>�2t1-t7t711 'is�15;f►J
J %IJtlLWI.1dC3 F0 _ l°00), 00
vAT)1
CL LL
` SC.Ji3s' :WAlf, COMMS R-Lifal0_114 tyD Pllmlq (73TECK
$333:60
.. .6al.1A1 J.".f:M "'S'�113..! A`A.,1;:9.�
SCJ 1117 '.
C9;1€�:�.> '.' > .ASI 3+'lh l ):Tla;.;�Jf3 V-' `
• $333.60
4
RECEIPT. '
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
F*rms & 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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Z4 g:7
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test OF
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final .
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
1 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)