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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
6515 �lU�:�112C
Date %� Signature of Contractor 1
..
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat 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 Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
O 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
pe formanceof'the work for wKich this permit. is issued.
have'and will maintain workers' compensation insurance, as required by
fiction 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 STATE COMPENtiATI Policy No. 0460006168.01
(This section need not be completed if the permit valuation Js 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 mannerso 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 P700 of the tabor
Code, I shall forthwith comply with those provisions. "I
Date: ' ril `. Applicant I
~Warning: Failure to secure Workers' Compensatid coverage is unlawfuhand
shall'subject an employer to criminal penalties and civil fines up to $100,001 L In ----
addition to the cost of compensation, damages as provided for'in Section3X
of the Labor Code, interest and attorney's fees. u
IMPORTANT Application is hereby made to the Director of Building and S
for a permit subject to the conditions and restrictions set forth o i
application..
1. Each person upon whose behalf this application is made & each parsLnawhose. request and for whose benefit work. is performed under or pursu
any permit issued as a result of this applicaton agrees to, & shall, inde
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null andvold.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 property for Inspection purposes.
Signature (Owner/Agent) '``' id' ' f� Date 'r J
BUILDING PERMIT PERMIT#
DATE VALUATION -3 LOT Z� r" �`4 TRACT
JOB SITE
APN
ADDRESS 79k.9.40 }TANCOC Y, C01TRT
OWNER "'6;
CONTRACTOR / DESIGNER'! EN (NEER
C'fa'iyj'1'�I.1t Y CROW1,
C-IAL-M:fl NIA .��' OLS & U.P.
13.1.5 5CX ND' ZTRRl T, UM 0:100
7,1725 J017IDPJAM, WIDE #A
SAN BEFWAR.i:97 40 CA 92409
'PALK111F'MYi Cts 92260
(260.21,40-9WO CIBlif 003f'>5
USE OF PERMIT
►-'OC7f ANDIOR 10111 1A
POOLAND ND SPP. ONLY. ALAt!i.1'+ WBAiy;UC.WS SHALL. E. 114 PLAGX PRIOR
TO PREPLA:14'ER IMP�;C'.`r�tON, P00b EQUIPM0I`I' M. 011,(M :fly R, NOT
INCLUDED 114 PERPAIT.
}BOOL .ANJ)1()Ti SPt1 ! �,llOtl.Itf1 t ai'
EST"Alm) COW., OF (110H.Ti7EiI)•CMON
PERPAL IT FEW S1UAIWRY
PLAN CHECK FEF. 101.000.439-,318 $12105
CONS'1 P UCTION VFW., 101-04 0-41 6-000 $130.00
VIEC HANICAI.. ME -- POLL 101-000-J121,000 $24,00
IS.i,EZTRIC AL VE — POOL, 101-000-420-000 $45.00
PLUMBING POOL 101.000-X119.000
APR 0 12002
IYOFLAQUl9� &IB -V '.t.AL r�t��r MUC11Or1 AVaf) . PLAN 0-JUMAN.
��c►,'.��
FI_�MED -'
i�1? � 1�i'�E•P�titL}�+ i�7
: t�.�t7
:TOTAL ]P1.'RWY:[+KlKS S1't7E .I OW
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RECEIPT
DATEBY
DA FI D
INSPECTOR
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
BLOCKWALL APPROVALS
Steel
POOILS _ SPAS
Set Backs
Electric Bond
L
Footings
Main Drain
- Z
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shaver Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sr wer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECT=AL 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)
COMMENTS: