0105-020 (RPL)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
C5�ry ,,rr3p
4e.iV,Y. dtGd 1..';M.
Date,S_ QZ4 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 pr602Yty, 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.
"( ),,61%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:
Carver Policy No.
TATE •C'�P4Pl�Ha4T.[ 040 %160
60
(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 wit those p ovlsionse7
Date< Applicant + • .j
Warning: Failure to secure Workers' Compens tion coverage is unlawful and
shall subject ari 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..._
efor a permit subject to the conditions and restrictions set forth on .his+, x
application. a> :t
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
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 for inspection purposes
Signature (Owner/Agent) Date " F'
BUILDING PERMIT PERMIT#
DATE VALUATION ,. LOT •
TRACT
$X9,9C" X10 16
237 7:4- s
JOB SITE
APN
ADDRESS 76 -WO MYTH WXY
OWNER
CONTRACTOR/DESIGNER/EN INEER
'F
�•�+g, 9�'/+Yyy� ta �•�y/y �y y+j y. �'qy. g�g•p�/� �y
�...hT„Ftl'.& Cpa.6A .0.:+fii4.71dY7�lw:t.rLr ��'W1V.�Y•F°aY ddt%0.7.
/ �'�y(�j�q} } •y v,r p (yy J�
�A'�3✓3s':'��.R1.tl#.�.R��.G�fA.M Ob. S.7.:ri'S,T� {.L �a�X J.tl1:; S7.'t �,i�i'..
is 3 5 ;30. DI, Vl'�r. 'd, VrE. "9200
RAIC'URNI A"WO CA, 9%�08
PALM I74, M."
CA 92240
(160)340-,9000
CW4 355
I
USE OF PERMIT
Ir"OOLISP.A. .kiLARM:iBi9ii!"lIiM SHAD, BE IN PLACE AT FRLP-PLAS,7'M
'
W.&PEC TION, P0011 ZQUYPh1RKT kJQ7', &1RE NOT 11l ►^I<i3DEI).
Y 4�
6
'1
Jit t�.I , A2 i"" 9i ➢fi P.r l A . Otf I's
IMI&F.0) Cola- W :CORiICTlrsUC')." OR,
1919M.00
FXRMUFNIRSONWARY
PLAN Cf IWXYMIE 101-000-439-318
OY3WSi`F'=111,,10W .VU'R - i iJi '00 1•d1133-(J"i2f $207100
; IEC,H)WIC AIt WE -- POOLS " 101-000-421-000 NAM
1a.FZT:R1CAt° FFA Y POOL 101-00-0-420- 000 OwN.0f)
Pi:{s 153ik� 3'79.5 --POOL, 101.000419-00-0 S71.00
HI) PX,
',WSS
PRTS-, E'AM F $0100
mm. lrt��J 1)cry. Vgow
37
MAY — 7 2001
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE f
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
�_—
Electric Final
Waste Lines THeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
e
Gas Piping
Gas Test
Appliances
Final—
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
i Main Service
Sub Panels
Exterior Receptacles
P G.F.I.
Smoke Detectoirs
- Temp. Use of Power
Final
c Utility Notice (Perm)
i