9809-259 (RPL)LICENSED CONTRACTOR DECLARATION
I 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
t N W Professionals Code, and my License is in full force and effect.
C :3ch License # Lic. Class Exp. Date
. r- Ci U-)61,1611 C 33 3131/99
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LLJ
�' II _
Z r -Date /^ 3 9,Signature of Contractor
J j
O� C / OWNER -BUILDER DECLARATION —�
_J
WW 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
r Code).
C'') () I am exempt under Section , B&P.C. for this reason
Ln
O N Date 'Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
C:) Cc Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: 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.
C0 Q U ( ) I have and will maintain workers' compensation insurance, as required by
C5 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
11 � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
ccb O C 7,Ai't.EIMOI ' N A'I , fl li%f if?(it? 14 At o
Q (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
ate: Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil finiis'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 ifs./
work is not commenced within 180 days from date of issuance of such f
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 property for inspection purposes.
OSignature (Owner/Agent) Date 1 ��►���-
BUILDINGPERMIT PERMIT#{}� CONTROL#
DATE f VALUATION J2(}�},�(} LOT TRACT
8346
JOB SIfE -J
!�OL 79!s CALLE GWATIf VIAS
APN -
ADDR SS`
OWNER
CONTRACTOR / DESIGNER / ENGINEER
BOBBY M!1, K IESIAN
NIC 1�4FrV'U 1.100 1, S & N P A S
50-795 CA1,1,H GUAYMAS
P-0. i3C X 1791
i,AQIJIN'FA, CA 92253
LAt;1U1N'YA CA 92253
(76(0Y_460.35135 CBL0 1945
USE OF PERMIT
PCXX, ANNoR SPA
1�>r. ed .�A �f�'L x , :U.wItAd,'i AN.G.rti_aft.13t�l23211aR 12Tr.�,.�11.%r�� ! Git
1412k.-KAyTER INSIJEC:rl[ON
POOL AIr'D1f. R SPA 20,00+11,00 LS
ESTIMATED C_QUI
20.€10100
>1°1+:RMIT FEC, StiP► MAlRV
PLAN C:tfi CK FUE 101-000-439-318 11SIM155
CONISTPI U7110N VFY 101 -OM -418 -OW T207.rltt
NIEC,1`1ANICM.1•`;:1s--.POOL 101-!300.42,-000 $24.00
is A.-C.I ICAi OX - —1&00j. 101_00 0_42&" it)
PLUMB INO FEE -- P(IX:i.i. l01- M -41y -1M 5:37.tN)
If3-ITYT:�1, CON,` 1YR 1CrION AN iNIE'CK
IAs
-A—NP�1
.417
4QCA TOTAL NJN,i3.l4tIT 1+'FF-4 3)11K1VOW
$437.55
®1
RHOPT
DATE
BY , • '
DATE FINALED
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
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
1.2
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
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
c
Final
Utility Notice (Perm)