0110-030 (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 %i Lic. Class Exp..Date "
Dade-Ae Signature of Cont. -
r .;:OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1. 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 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 9`under penalty of perjury one of the following declarations:
O 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 3,700 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 ST.hTRPf.FND Policy No.
(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 the workers' compensatio pro visions of Section 3700 of the Labor
Code, I shall forthwith comply withthZse pRovi ons.
.Date: /) "! t, Applicant—
Warning:
_ .5+ ;. M . ,c•:_'
Warning: Failure to secure Worl(e ' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition'to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made,to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
,'any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit„issued as a• result of this application becomes null and void if
work. is not commenced within 180 days .from date of issuance of such
,permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is.
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this'City to enter upon
the above-mentioned prope fo iinspection purposes.
Signature ,(Owner/Agent) "''rte” �-��'^�--� Date!-•'�
BUILDING PERMIT PERMIT#
DATE VALUATION ®� LOT . TRACT
JOB SITE
ADDRESS N)1 -22t$ VIA IM' M DA
APN y
OWNER
CONTRACTOR/DESIGNER/EN &NEER
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1425 R Wi V+.Cyl`! IU A DJ1S N.A:., .,
PROk" AZ 135034
PHO MIX A7, 85034
(607)257.16556 C: TJ' 4990
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USE OF PEnMIT
xOt?.i.W.A. ,Jlisfl.RltR.^afitARRIUS SHALL iiK lti PLACE MR' S�1�IAA� 37'FW
114-SPRCTIOV, POOL EQ'tJ'tPMCWT ENCWS43RC'NOT 1).4 y"mr. .
- y
P001, AN WOi1 ,SPA U
XffrMAI.D CONT OF {wOhvei`8`iKLip..R`iOiP
.9q�1 .4fl4�
11,MMIT FEE A 44<FARY
3'IA14 CIfECK FEE 101-000.4.39,dfl% $101.30
COT€.. TRUCIT'low kf+ f fl•f3UCi tli-�?4�i $laC.fftl
)AZiCHAVICAL19JT,. 'POOL . 101.000 -421. -OW MAI
tf.'.-1, 4,G'1'l:1mm.. Fne ..- POOL ' 101 •M)0.42C-000 $45.00
rLIMM140 f -• POOL 101-0009-419-000 MAD
1110TAUAaMMT F220 DVD Now
RECEIPT
DATE % r
BY
DAT FINALED
INSPECT
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
Steel_—
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test
Final
Gas Piping
�c�
/
PLUMBING APPROVALS
Gas Test
-
Waste Lines
Electric Final
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
7=2 O -2—
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)