0108-137 (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
Date ° '' V Signature•of Contractor
`u.y' 1 a... -,y+•. .«._.,,,,,'�,,uy.. N. }�
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 property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
O I am exempt under Section B&P.C. for th"is rea961)
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
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:
Carrier Policy No.
STAIM FUND
(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 soto become subject to the
workers' compensation laws of California, and agr�e that if I. should become
subject to the workers' compensation p kovisions of. ection 3700 of the Labor
Code, I shall forthwith complypith tho�-e' ,,,Q!1ions.
Date:' ti ., Applicant ti '
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 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 represe°ntatives of tbis,.City to enter upon
,'the above-mentioned property for'tnspAttion purpti§es.
! t�
+Signature (Owher/Agent;'' ,•f'' '� ``� � � Dater�t ,
BUILDING PERMIT PERM T#
DATE L VALUATION LOT TRACT
j.
JOB SITE
APN > ,
ADDRESS
54-475 a4aWN)D A ' 4l LTA
o
OWNER
CONTRACTOR / DESIGNER / EN (NEER
''..ev3 .�>, t % . CP.� F
4 L, JLf �-XV e ra 1;.AC&ION OOU
54-17 5'AVINIDA "MIA
95 ZZ DQ- NALM ON IM
LA. QUMA
lbcq m VAL"LFy CA Q2:3.56
(760)Z48-6045 CBIR 431;5
USE OF PERMIT
i
:POCvLAIRWOU. 0Pk
lsd: 01,073fiyY..t l A.�Q1.14:JfD.Ail �:Y+RRA'011A.l..d 115Ikd:PLA EfxiW L? M.�°�ASTRA,
INSPECTION.P47OLt3IPWYNT fin+. CUDOURR NOT WCUIDED,
POOL ANINOR 04PA 1.3
WEBUTED COST OF ComInRUMON
0,000.100
.�1f'ilE RJiMARY
01'yW°qad1R
PLAN 04h9 A- 101 -OW -439418
M,
CO13'°tZOerricrm rap, 101 -000 -4,18 -OW F00
ctwwiTlMU, 1R - POOL i.'m.0oo-42,0,VQV AD
'
�1„�.tlullcx?�c�>�P��• 1��i��, f.t01-f�t1�-�i1�-�`'>&9t� �'�.�F
f
AUG 14 2001
CITY OF LA
QUINTA
FINANCE DEFY
UK= FTE -PAID )TEM.
WI. Of)
TiTAI', PES' FEES DUEOW
SIMS
RECEIPT
DATE. ( d
By
D T F ALE
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
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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
-
���%�
p
.�
Final
Ut ,y Notice (Gas)
ELECTRICAL APPROVALS
T . 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)