0401-099 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
v 483498 B C53 12A1!2(
tiLU
Z Date t i Signature of Contractor��' ` J
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CO 0�
J U C:) OWNER -BUILDER DECLARATION
WUJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this.reason
LO
N Date Signature of Owner
ON
CA
CL Q WORKER'S COMPENSATION DECLARATION
o Cc I hereby affirm under penalty of perjury one of the following declarations:
U-) H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W L= 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.
m Q L) ( ) I have and will maintain workers' compensation insurance, as required by
O � Q Section 3700 of the Labor Code, for the performance of the work for which this
d 0)— permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier STATE FUND Policy No. (68023(1-02
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(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 shallforthwith comply with those pro visions. /
Date:
I L
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
111111 of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
R*
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 representatives of this City to enter upon
the above. mentioned•prope rty,for inspection purposes.
✓ Signature (Owner/Agent) Date
BUILDING PERMITPERMIT#
MX -499
DATE , / ' VALUATION LOT TRACT
JOB SITE
i-ADDRESG
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
J OF,
aP. LP1(= POOi -D AND CO)ITSI i UCr.ON
78.645 MUM UTUR E
P.O. BOX 1524
L -k QL71N 1 A CA 92225'<
PAt.,?..Ei DEMMA 'T CA 92261
1360)568.4963 CrU(t` 7255
USE OF PERMIT
POOL ANDADR ORO
PGOUSPA ALAtthd,WI BARRIFER;.S SifA.1.L FBF? YN P'LAC1? AT PR&PLASTER
IMPECTION, EQUIPMEHT DJCUNURE NOT INCIAT EM
POOL ANNOR SPA, 1.5100 s.00 is
Esa''[IMAIXID MITI, OF CO.1z1'�e"Y?2i1C:" 01'T
:5, i:�. o
P IVW. ,r A� M&MRY
PLAN t".I•IEGK RE IM -000.439.318 X105.'0
C NS1'1iUCTION nX 101 000-418-000 $162.00
MECl1ANIC.A•L "fTZ •- POOL 101.000-421.000 $24,00
F,LECTRIC{ L MreT, - POOL 101-.0450..420-000
P LUI'd1131•I` G FEE - POOL 101.000-419.000
SUB -TOTAL CONMRIJr—?'ION AND P'LA9 C MCF.
$363.30
i93 Py -P 71D S
$0,00
)�.
. JITS w1L7
3130qIryrypit��
JAN 13 2004
CITY OF LA QUINTA
TEB..y�('^
DATE FINALED
INSPECTOR
Rik M"U149111MA... ft "'6125A
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 - IM. Lath
Final
Final
Steel�/
Electric Bond
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Main Drain
j_
Bond Beam
Approval to Cover
Aj
Equipment Location
I
Underground Electric
r _
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
Encapsulation
s � _
Gas Piping .
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Z r CITY�F LA QUINTA
BUILDI G & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE 2 -o4 S-7
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3
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