0104-274 (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
01 if)
Date ° Signature of Contractor
rOWNER-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).
O I am exempt under Section B&P.C., for this reason'
Date Signature of Owner.
WORKER'S.COMPENSATION DECLARATION-- '
O Z' I hereby affirm under penalty of perjury one of the following declarations;
Lo T p (.) I 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
O Q performance of the work for which this permit is issued.
co < U 1 have and will maintain workers' compensation insurance, as required by
O V, Q Section 3700 of the Labor Code, for the performance of the work for which this
L rn H permit is issued. My, workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
coO ST k,'i Z COW' �"t O FU'
J
(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 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 th7 workers' compensation prq/isiovof Section j7�0 of the Labor
Code, I s4pI(Pfo h ith Comply with thPpro
Date: .r . 1.. Applicant
%- --Warning Failure to secure Workers' Compensation coverage is unlawful a
shall subject an employer to criminal penalties and civil fines up to $100,000, D
addition to the cost of compensation, damages as provided for in Section 37
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on h
application. .
I
1. Each person upon whose behalf this application is made & each person it
whose request and for whose benefit work is performed under or pursuant o
any permit issued as a result of this applicaton agrees to, & shall, indemni
& 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 Yoid 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 l have read this application and state that the above information is
tt • correct: I agree to complywith a11•.City, and State laws relating to the building
construction, and'hereby authorize,�epresentatives'of this City to enter upon
the above-mentioned property fbrrin ,peeccttion purpose �
ign,% J�
Sature.. (O.w•,ner/Agent) Date4h/
,
BUILDING PERMIT PERMIT#
DATE / I VALUATION LOT 01041-274 TRACT
`'` t
�J ' G•. ti �.rt 4 'cs. "� �v
WVp'L71�5�.417d a
JOB SITE
APN
ADDRESS
47-090 YM ORMW
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ManzrNmu-soullfwn—r nomaNT..
mok'ammira"Umum .revLoliumT
7.7-MA-A.cot W..?Y C:LUBDR011
7? -564-A COMM. #113
TIAUA DEMx�J3 T CA 92211
PFJ M I We:>' RT CA 92211
(760)4083 3495) ( m-11 6 ai�;l
USE OF PERMIT
PC:X ?•, d:_N3:,f01. WA
AIDE IN kPt ACIV,AT PK+&PLAS'3'7?;R
01'24139070t.100,11, k:QUIPWINT KKU)SURY 1407 tNC:t,UDW art
PFMAIT.
%'?C3O1.•ATiY. IOR1, SPA $A010 LS
y
— n`Y7.�'4f��y`���4�6b�ffi!�8f—.N
r7,a?•Y�f{��oSYO
PLAN C REC K ME, $64.33
C;.rJA1-71r1"R21't"Z ION:fUVI : 101 -000-418-OW $99.00
WCHM1CAL �'s�� w...POOL 101.000.4ZI.000 &.2.4.00
$!$ A,` WCAL ;PEE - POOL
PLUMBI O M. POOL 101 -000.41.9 -MID �2➢,01►
APR 2 6 2001
y
777- CITY OF LA QWi' ' • C 9 �' kCi IC7k3.f r� 1 jT.RiN' 3?sCX
-
FINANCE
DE
'N S -PAM Ir s
2*. f30
RECEIPT
DATE J' •
BY.
D E 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
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
f t�
J
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
Sewer Lateral
Sewer Connection
Gas Piping
O.K. for Finish Plaster
Pool Cover
Encapsulation
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
Final _
Utility Notice (Perm) -