0110-026 (RPL)LICENSED CONTRACTOR DECLARATION .' .
I hereby affirm under penalty of perjury.that 1 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
Date r �`�s Signature of Contractor `f r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner of the property; or my employees with wages asAheir 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 wlin llcensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I arri'exempt under Section B&RC. for this reason
'D'ate 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
perfor ance of the work for which this permit is issued.
Mhave 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 ;1TA-TE MWENS.ATI Policy No. 0414T61"
(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 ie, 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 the workers' compensitipri provisions of Section 3700 of the Labor
Code, I' h II forthwith comply with those�provlslo s.
Date: ^ % $ Applicants v' f
Warning: Failure to secure Workers Compensation coverage isunlawful 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 Safe®
for .a permit subject to the conditions and restrictions set fort h% or� —
application. 31
1.'Each person upon whose behalf this application is"made & each"pers • a
whose request and for whose benefit work is performed under or pursLie t
any permit issued as a result of this applicaton agrees to, & shall, Inde ni
& 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 v8id_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.
Signature (Owner/Agent) ^"11
L,'��j°�''f Date%
' BUILDING PERMIT PERMTk
DATE r VALUATION LOT TRACT
JOB SITE �` :
APN
ADDRESS 44— VA C�..f� . ADO
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
44.2165 VIA, W:CtC)INADO
747205 JONT TAME, SME, #A
to QUIN T1'a CA 92253
T' UM ML?.Iti"T CA 92260
Cf3� dS?„ QSvt G'Ek '355
USE OF PERMIT
P 1.-1*T.Df01Z WA
10ODUSPA A:tARA2iAsli+k IERS SHALL B& IN PL, -C E A'T .Pi2.9•Pt.ASTr,.R
.•_PC OLEQUIPMENT IRWIX)SURE NOT MCT;UDW.
POOL AND1I.: k NRA LS
Orn"TED COST or COMMUMON
18,W0.00
PIAN CHECK Ful 107 -OW-439-31 8 3P2&W
Mk+'WNzCAL ICU • POOL 101-000-421-n000
S'WMDaWE1 KV, — .PO- OL 1011 -MEQ -4194000 $ 1.03
��sacn01�IM 1)-psam-exOCT 04: 2U0 �
^.ITY OF LA WINTA
FINANCE DEPT. 1jy,)TWI FlU d wFir"ES I TE 1'a'OW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
P.`.
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS '
/p=o
L
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Final
Underground Electric
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
C`
Wast '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
ZjZ /_ U=
i�O
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)
COMMENTS:
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