0102-169 (RPL)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
C5 31
Signature of Contractors
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
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 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 Policy No.
WHAUJAMMAJ11a mg., Mot 0934-0,
(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
., ubject to the workers''' compensation provisions of Section 3700 of,the Labor
Code sh II four with comply,With those proy,.isions. ..k
Date' APPlicant 2 P .x,...�s''��
Warning: Failure to secure Qrke ' 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 & eachperson 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 anis 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.,guthorize representatives of this City to enter upon
the above-mentioned pro erty for inspe¢tion purposes.
y_f
Signature (Owner/Agent) Da e
BUILDING PERMIT PERMIT#
DATE/O ` / VALUATION LOTwTRACT
JOB SITE
ADDRESS
APN
X4,MMM119 WAY
OWNER
CONTRACTOR/DESIGNER/EN INEER's
R.MMY HONMI
M:C1:NTYRE POOH W-6115
81-1201�:OM°t��''�t'A�Y
:.}10, RKA 1791
LI', QXWfA t k 922S3
LA pt °1'A, - CA 9.253
Ci6o iso-35si- -CRU; 194
USE OF PERMIT
POe;, L .&MYOR, SPA
POOL & WTIA. A1.&1W3113,AJRR1XM1 S AI,1, BE IN PLACE AT
z-01c,-'J.AUT0,11TIME ':TION, POOL HOUiPMENTFIX0,03tIRS 1:3`HOT '
:33 a:131t:i3,
0001, AND1011 t9i3A s v,%}D 111a
r6rI �i,�i�s.F.�X G0sir �:� ��i� F ><
PLAN CHECK 11M
MECHANICAL .-- POOL 101n000 -42.1-00f.
R.ViZT-.X1.lPEP, -v POOL 101-0,0-420'000 $�0.0��
pf"UMBwana-pco� 101.000.419.000 MAID
.Y« 0 .Til? i�
C.i3t3
Mr
RECEIPT
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
Final
Gas Piping
Gas Teat
PLUMBING APPROVALS
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
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 (Perm)