9907-522 (RPL)LICENSED CONTRACTOR DECLARATION
VIP 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
N ' ' Professionals Code; and my License is in full force and effect..
O cM License # Lic. Class Exp. Dated
W in oe
636128 CMr 0/3112((
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r* -
Z ►Date `l A'� JSignature of Contractor
CD 17/
U OWNER -BUILDER DECLARATION
W WW ~ I hereby affirm under penalty of perjurythat, l am exempt from the Contractor's
co License Law for the following reason:
Z ( ) 1, 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).
M O I am exempt under Section =, B&P.C. for this reason
�► Date Signature of Owner
Orn
a'< WORKER'S.COMPENSATION DECLARATION
o*�Q � I hereby affirm under penalty of perjury one of the following declarations:
F- O O 1 haveland 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
mJ Q performance of the work for which this permit is issued.
<U ( I I have and will maintain workers compensation insurance, as required by
QQ Section 3700, of the Labor Code, for the performance of:the work for which this
a10
H permit is issued. My workers' compensation insurance tamer '& policy no. are°
It Z Cartier Policy No.
r O STAT': RYIND Q)tt�-�1)_JllfiF•i�`1u
g (This section need, not, be completed if the permit valuation is for $100.00 or less).
O I certifythat 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 "�bject to the
workers' compensation laws of California, and agree that if l•should become
subject to the workers' compensation provisions of Se X00 of the Labor
3 Code, 1' II rt with comply with those provisiogsFrr
Date: 'L %pplicant
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 ab ve information is
• correct. I agree to. comply with all City, and State lawseating to the building
construction, and hereby authorize representativ is City to enter upon
the al5ove-mentioned property for in pe r s, -s.
i
/Ignature (Owner/Agent�,,•�Dates -�
PERMIT #
BUILDING PERMIT
DATE/ VALUATION sn'74mic o LOT TRACT
112-1 �, 6.
ADDRE S 51i- R5 itdKr� YPIER f;l,EN
APN -
OWNER
CONTRACTOR/ DESIGNER / ENGINEER
LA Qrll;N'TA ORC1ii1:'l':1i PAIR NERS
CS?.1.lT't RNIA POOLS %SI3.AS
PCS 13OX 1'716.
74-725 JONI i:1M VL, YA
LA QE IN'[A. CA 9:125:3
a>ALM. f7[:14.,K7` CA 02260
3760)34 Y-9000 f SBL # 355
USE OF PERMIT
PCXUX, A:itiilXOR NPA
P00L & ,tiFOA.!% WQ ONLY. h�f:.ARM&Dt1itJ2461ZS 5i4't>i 113E IN K&UF Mil
'f"1!4fks CiF I�1tt✓-l�I.A.�s`I'1� 71�FSYs:.t:"fiC,�'.v.
I 8,700-W LS
6'1f KWf FEE u8310 N[jtfl Y
E�Ltt„J +'” C",'K FOE. 101-600419-318
coNi p'Rt %7IO_'rl vvl 1014Rt1t)-4,19-0N?4.t n19F3.00
AtF01ANLCAL FIM - r001- .1,01 -000-121t-f ) �7A tJP!
1`LEA.' rRICAL 1:FE--
PLUNIIiINGF%E---11-CK . I01,-ok-119-000 4�:r7.ifr7
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(',t;)iJ;,TICI;'.`r`101MAND 3r'1.,.AINJC,BfICK,
LES c PRE -PAID Pf,t:
Sr�.f1f�
'['O"t'AL PF,f{t6ITIr FEES DUE Nt
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f
RECEIPT
DATE
BY !
DATE Fl
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
BLOCUKWALL APPROVALS
Steel
Set Hacks
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
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
Final
Utility Notice (Perri)