0112-100 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisioe-siif
FN— Chapter 9 (commencing with Section 7000) of Division 3 of the Business Ad
C14W Professionals Code, and my License is in full force and effect.
oLicense # Lic. Class Exp. Date p 614611 C53 G3/yIt'2C
LV
oZ ��'Date/2' /1' 01 Signature of Contractor"t
ca O.�
J U C OWNER -BUILDER DECLARATION
HWID_ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
C () I am, exempt under Section , B&P.C. for this reason
^t Dato
N Signature of Owner
Q
Q WORKER'S COMPENSATION DECLARATION
O Z IM I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W u- 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 U (gyp I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
li rn H permit is issued. My workers' compensation insurance carrier &•policy no. are:.
Z Carrier s"�:9'F: ")ND, Policy No. 046-V V010467
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J(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, J shall f rthw'th comply with those provisions. 4 ;
�+ Date:!/. �',r Applicant �• `..� , __•. „""� "�
Warning: Failure to secure Workers' Co p nsation coverage is unlawt I and
shall subject an employer to criminal penalties and civil fines up to $100 M0, in
addition to the cost of compensation, damages as provided for in Secli 6�"`
of the Labor Code, interest arid attorney's fees.
IMPORTANT Application is hereby made to the Director of Building a fetyn
for a permit subject to the conditions and restrictions set fort on his
application. <
1. Each person upon whose behalf this application is made & each p rson at F
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 andmemployees.
2. Any permit issued as a result of this application becomes nu1f 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.
t
I certify that I have read this'application and state that the above information is
• correct. I agree to cornply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned roperty for inspection purposes.
Si nature (Owner/A Daet '"7���'�
v, `
BUILDING PERMIT PERMIT 0112-100
DATE 11',,11/200 VALUATION � r _ 9 x. ,4 LOT 33 TRACT 2W.38-7,
JOBSITE 8J_2W Q()LF VJM..DR+JVJJ.
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
81-220 LUGUMD9 WAN"
I'10 -BOX 1791-1
LA QU.WTP. CA 92.253
!A Q? r. WTA CA 92253
(760)360.25€5 ":4 . C' lh 1945
USE OF PERMIT
P001, AND= SPA
,•'Y
.•'l,e'S4ID
N 1itz 4!': AT
WSW ` IOW. POOL'f.X11:1PMIEN1? ENCLOSURE, 114CWDED
t
POOL AND/OR SPA. f;`alf"Im 1.2
�
MOWED+CQ3'.f 01F CC"►iW'&M.17010N
PLAIR C34ECK ME 101.001 -439 -Mil �IQS„S6
CaNSTRUCTION FEE 101-LOOO-419-000 $162.00
hirc1`119310ML "IF •- Pool, 101.0900.421-000 $24.00
F.):.l c, TRIC,A1.1''EE -..• 1POC+ 1191-0004 20-000 $0.00
PIJf.:T.ttABING FEE pgii)L 1 i € 101.000-4.1,g-000
t
r, 11 2001
X_ CEWEP :". CO'TALC".'ONMUCT1.411'A°N.0111:A.9<.r.1`'I1iL=-,
$36330
L FSS TYKC.-�PAEDFBES
$0.00
_ 710TALP.EMAT1' IMF$ DUE; NOW
RECEIPT
DATE' /�� j J.
3%` �....r- "
DATE FINALED
INSPECTOR
i k,
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
0
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 Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
A;�aliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbxtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final`�'G
_
Utility Notice (Perm)
/