0101-265 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licenser' under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professi,onals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
C53 00 03JI31/v
Date/`� i Signature of ContractorT�"""""'"'"'
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
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date r 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.
(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 3.700 of the Labor
Code, shall forthwith comply vrjth those provisions.,/'
Date:/_"2 5"T 00 Applicant Z'J =--.s �•.1'�C,---^, ""'"'�
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. e %
IMPORTANT Application is hereby made to th'e Director of Building and Safeat�
fora permit subject to the conditions and restrictions set forth o his
application.
1. Each person upon whose behalf this application is made & eaob rgnW&
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 pfoperty for inspection purposes.
Signature (Owner/Age )t= Dat/
BUILDING PERMIT PERMIT#
TRACT
DAT 1.7�'/{,/ VALUATION LOT TRACT
JOB SITE
ADDRESS
APN
✓�:J,_��t) �07a7,f"i!1'Lt:t�1.�Yetlr!�
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
P"Maly TI;�� lkNI i 4C.
ivvf� r� X Ems; � ,I.1 SpAq
23 C"OF.-KIRAME'PLAZA, 07,45
LOX 1791
:tom" IAOR£T , Af. H CA 9::"660
Iii Qu'N,11% C.P . 92253
t;7 J fn 358w CB1,0 > 194.5
USE PERMIT
YOF
yD p Cy
VA
POOL a SPA t~dA31.Y-JUARl+ IStRARJUEVN1.5}iA11, 8E Ti PLACE AT Pkk
PLASTER W.MPMk: IT "IMOSUR14, JS NOT 04CLUDE D
IN I HIS PERMIT
P00.1,AND-10R,, SPA U11
1 9111 :MD COST, OF COF3S.M.Lyallo."
PLAN 011XCX VKl, 301-000439-318 $105.30
d:." NSi'zl,P��id��7�'IEJ'E 111-000.418-000 $162.00
1NlECHAlif6 L FEE -• P41101 %24.410
&WTk li.'AL, Vt x• J 0011) i01 -000 -420 -OW $45X0
PIMMM,41 Ygle, -- POOL 101.000-4.9.000 W00
Z'{. R-11 L'.i AT, Cf..rN18MXX.�.I,AO.N AND P«L!'�'+ 4r1.'3ECK
$363.30
MEW 'PRE -PAID MWS
$R00
4 a
RECEIPT
I DAT/ .p �.'
`
BY �,..•-
(
DATE FINALED
INSPECTOR
D0�/Vi)
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
�h
Set Backs
Underground Ducts
Fom s & Footings
Ducts
SlabGrade
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 BondG6/�l
-
Footings
Main Drain
Bond Beam
Approval to Carer
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
_ _
6
"
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 Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation9�0/
Gas Piping
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)