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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provir61n
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
789540 R i C:
Date G/– 7 Signature of Contractor f /
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, 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
cohtractors 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 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 ,q
TATF_7(j14D Policy No. 04400"20227
(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 sho Id)become
subject to the workers' compensation provisions of Section 37 • of the Labor
Code, I shall forthwith com I with thos�Zrov'sions./"
Date: t S=_. T Applicant / /p •1 .1
Warning: Failure to secure Workefs' 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 O'uinta, 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 representatives of this-Gity'to enter upon
the above-mentioned property for inspection
Apurposes.
Signature (Owner/Agent) �/� -'Date 7-y �J
�, BUILDING PERMIT PERMIT#
{{11{{
VALUATION LOT 020.3-4W TRACT
JOB SITE
ADDRESS 80-M) AWNWA HKIRil
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
X;.[. PJAM.0 N HC.'+W BUILDW I,'+iC
ALL AMIMCAN HOW BITWIMMS INC
76995 F1_.QIMMAiIMM
7695 IWRIDA-AVI?IKIR
PALM DEEM CA 92211
P,'LM. i?MIM CA P2211
(76Q2001.02-77 CB1.41 ('03173
USE OF PERMIT
POOL Ah``WOR, VA
POOL ONLY. NO f•IKAEP, ALARMSfS.f KRIiEk's`,.S SHALL Ht IN PLACE
PRIOR TO PREPi.MYER 4ROPECTIONI POOL hs~ UIPWN'T EI C1,00I,IRE NOT
INCLUDED IN I'LL MIT.
POOL: AN WOR SM 61500.00 I,'S
Eb"IM <3 COST of, t 0Pr1:MRVC1'IO.t1T
615(x oo
PLAN COFICK PEZ16-400-439-318 toto+
CO S I'}i UC TION FEE 101-000-418-000 $90,00
I+ `TlkiCnlLtxiR E •,= POOLI.4)I-000-�42C-0001 $45,00
PLUM81140 PATE ,. poat.. 101-000-419-000: $27.00
• APR 0 12992
C ffy QEF LAQUIKrA
F1, MAN PCIE
a
,p
S1,14Al'OTALC;ONSTRIl4.".'l�i.?I+i 1%KD YILAP;I �.�1D '
$22€,50
M03 PRE -PAID RUM;
$0,00
TOTA10 r-fMMUFE131 TATE
&'2;20 x501
RECEIPT
DATE
BY
D TES IN ^
INS PECTOR
:
11 .. r _1
c K/
X01` tz-1*01 0
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
POOLS - SPAS
Set Backs
Electric Bond
D
Footings
Main Drain
_
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg, Test
Q-
Figl
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
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)
Final
COMMENTS:
31
I
''---------, - -----
lea
t! o USS"
CITYOF LA QUINTA
BUILDING & r§A%FY DEPT.
APPRO
FOR CONSTR��U�CgPOQN
BY
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ,ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO EXCEPT ONS!
.. .......... ..
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