0403-337 (RPL)H
fV LU
LU
O =) M
�w�
iDZ�
O O
CD
_J U �
Awa
U
Z
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
t'6612€f C53 Fac; q.4)1W�1/0?
Date. -' '���3` / Signature of Contractor f f� 7 �1r�%✓
OWNER -BUILDER DECLARATION
1. 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 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 permittis issued.
I have and will maintain workers' compensation insurance, as required by
S ori 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 TATE rC01,4PDISAT) Policy No. 046-11316' -Ml
(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 mannerso as to become subjectto the
Workers' compensation laws of California, and agree that if I should become
subject,to the workers' compensation prgvisions of,Section 3700 of the Labor
Code, I.shall forthwith comply with those'previsione/ 1z
Date:
Applicant �rdr
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 authorize,rgpresentatives of this City to enter upon
the above-mentioned property for'insIlectio 1purposes.
Signature (Owner/Agent)! -1 �/
Date
BUILDING PERMIT rt"M" A ✓
DATE, . VALUATION LOT C:°4b 3 -X47 TRACT
r $44:41KIXIA)
JOB SITE APN
ADDRESS
SSD-2:if 15 `H7GLEN .. ,.
OWNER CONTRACTOR / DESIGNER / ENGINEER
T.D. K71 ry 'a :►_?!s1(F 1 3} tv�l`1't' Gtii;I>N' s 1 P,0i tiY.r`: 4 JP1W�'YL �:=i .PdXG,;tip C-01
.P:).: VIK 1'716 R6a)0;0A`1Q1zY1TL154
t..1� Q'UWA CA, 9225'3 COACHELi. A CA. 92236
('i6f1�"a9S� a 2 (TL4 00355
USE OF
P011iL !!�'"D 71z ;f1 _A
WATER FIATti'RE ALA NIS(BA[;RUERS SHALL 13F. R4 PLACE PVI,1JR 1'0,
#'IU€�t'i.,0T RIk WSPltfi110H.
POOL ANL'KM ,..PA
41090, D10 Ix
Et'D II/fAIRD COUr WT C:01*►:C.f2'U(7fION
P]li :FWJT la`IM &i:►1�i`tb/iAR.'Y'
PLAN CHECK FEE 10, .:V0010311)-318
CONSTRUCTION ION FEE 101-000_ 181.0 0
icIECTY2,ICAI, F1,72 -.. POOL 101.000-420-00 t
PL! UTAP-11NIG r'FF F- P001, 101-00111)19-'L}W
SYUB-ITS'1`.AL, C"014W- i J0T1()A' AW_ D PLA14 OITECI
LE:'; 3 PR.7&�1'b (,k T,'9R.4
U,.1 IJ a_.
MAR 312004
NI
CITY OF LA OWNTA
IL26- DTZPI
RE ATF BY DATE FINALED IN9PEC70
11,. • I I _`�_ 7n -- .-L
4.900.00
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 a SPAS
BLOCI4WALL APPROVALS
Steel d
Set Backs
Electric Bond
Footings
Main Drain
Bond.Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Foal
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
-f 5
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)