0108-121 (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
157412 r A G53 HIE; OW3142(
Date t � l t/ Signature of Contractor'.1-r.
""-�- OWNER -BUILDER DECLARATION
I hereby affirmZnder,yenalty 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).
( ) 1, 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.
STATS, FUND 046- f3"Q,1"434
(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
subject to t 'e workers' compensation provisions of Section 3700 of the Labor
Code,J sh II forth °ith comply with those provisions,
Date:f''E r„+a Applicant..,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalti;ps 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 representatives of this City to enter upon
the ,above-mentioned property for inspection purposes.
Si nature (Owner/A ent)-�� Date � W5
BUILDING PERMIT PERMIT#
DATE % VALUATION LOT �,� TRACT
t/
yy �qQ�
JOB SITE
ADDRESS
APN
814 7le.EC`r,€j;r', DS WAY-
-
OWNER
CONTRACTOR/DESIGNER/EN (NEER ti
r
,@ K 940 YO K3i�,IAE AVE 0200
73013 MUMMY MUB DIL, SRI TT04
,IRVTNE CA 92606
RAUM DRAW. T CA 92260
C?60),346.40371 C,1WW 1044
USE OF PERMIT
r� 3L'ib�VAL ALsI,RAISIW�RTM SHALL BE IN PLA CL AT l IMPL AS7 ER,
'WSf'E::1.': ON, POOL Q:QEi9PM.E13T Mt".y.1fiSUR :140 9' I1atCLUDIM,
P001,AXWOR SPA 1.9
NIS "�'.��.1 I"�1:3 COST OF CLJMMMON
24AMM
flt' l-TYOM RUWMARY
f.
PLAN CHECK =1, 101.300439.318 $163.80
+
t' IC)taS'i'`RYICTION IAF, 101440418-000 $232.00
MECH 343CAL MR - POOL 101-000-421-000 $24.00
M.s CTRIC'A L J�Mf a. P,001, 101-000-4 0••0t;4()
.m.,umi'mo Ira POOL ioi-000,419-000
g 0 e
AUG 20 2001
CITY OF LA QUINTA
FINANCE DEPp
RT�B-TCTAL t`10NITK:l'MON AND :RS. ii CHECK
$511
IM& PRE-RAAD IM, ES
20.00
TC��'AL�'' P=al* �1;I�' "1fK�9�1
M-
I1.80
RECEIPT
DATE �i'
1
BY
DATE FINALED
INSPECTOR
9 9 7
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 Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS
A / —
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
_
Underground Electric
Underground Plbg. Test
—
Final
Gas Piping
-6 — - --
PLUMBING APPROVALS -
Gas Test
Electric Final
-y
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
Gas Test
Appliances
Final
2L