9905-184 (RPL)C6
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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
WM20i
/1Q_ n Lract:_e�
Dat 6ignature ofCo
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 1, as owner of the property, or my employees with wages as their sole
como*ensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). I
( ' ) 1, 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 . Signature of Owner -
WORKER'S COMPENSATION DECLARATION
1. hereby affirm under penalty of perjury one of the following declarations:
,�O'l 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.
S`I-ATS' ]TOW1.1 0105-A. Mo
(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 s * hall not employ any person in any manner so as to become subject to the
workers' compensation laws of California,.and agree-thArif I should become
subject to the workers' compensation provisp'ns;-o-'f'Section3700�qf the Labor
'provisions
Code, I shall forthwith comply.with those
App!icant— 1 All'
Date:
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
.2. Any permit issued as a result of this application becomes null and void if
*work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby auth6ri-zle representatives of this City to enter upon
I .., I
the above-mentioried prop�rty fdrinspection,purposes.
Signature (Own r,/Agentl Date
PERMIT #
BUILDING PERMIT
"0444
DATE VALUATION LOT TRACT
JOB SITEI I
APN
ADDRESS Sft-645 GILVNDT RAVERSE, AVE
I
OWNER
CONTRACTOR I DESIGNER ENGIN EER
R-111� HONIES LLC
PO BOX RIG
1,425 F. UN1V.ER.SFFV DRIVE
LA QUINTA C A 92 2 53
PHOENIX A2. 8N)34
(6 02) 3, 57 - 16 5, 6_5 ('11,131144 49(M
USE OF PERMIT
POOL AN' Di0k SM
PGOWI&A. ALARMSfBMAMRS SHALL BE IN AT 111kFP_$A6TER
I.NSPEC"rION
POOL AND00% 3'PA, I L00.00 LS
GIMST OF
'PRIMM—UME, SUMMARY
11. AN C11fi- CK FFKH 101-000-09-318
C-0— W MXr! ON FEE 10! 440-4! 8-0(110
AWCHAIC-CAL FEE — POOL 10 1 _000-4.1111 1 Vo 1^44-00
REMICAL FER POOL 101--000.41,20-ow $45.00
P)JfJNffl1t%'G FE% __ POOL 101 -ON -419 -OW $27.00
SILIBVR�I'Al, COMSIT UCTf ON AND RIA N (T F CK
0),k0f)
LE SS M-3-M.'D FEES
W14.00
'VOTAL PERMITFUTS DUE NOW
$303.90
RECEIPT
DATE
BY
FINALED
FDATE JINSPECTOR
el
I
INSPECTION RECORD
0 RATION
PE
DATE T
INSPECTOR
OPERATION
DATE
INSPECTOR
B UILDING APPROVALS
MECHANICALAPPROVALS
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
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
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
e16-,_
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
Apoliances
Final
Final
UU14 Notice (GAs)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring.
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.L'
Smoki Detectors
Temp. Pse of Power
Final
.Utifity Nofice,(Perm).'�.
COMMENTS: