9903-095 (RPL)LICENSED CONTRACTOR DECLARATION
Ii'h'e're'*
4 •'affirm Under penalty of perjury that I am licensed under provisions of
Chapter. j� 9`(commeficing 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
5 -3
35 1.6-7` C I
VDBte':: Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjbry'that I am exempt from.the Contractor's
License Law for th6 following reason:
11, as, I owner of the property, or my emp!oyees with wages as their sole
comp6nsati6n,.will do1he work,and the structure is not intended or offered for
iale"(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
C6`dej.
1 -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'
compensa ton, as pEovided for by Section 3700 of the Labor Code, for the
perfo[rnance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
�Pction 3700. of the Labor, Code, for the performance of the work for which this
06rmiuis. issued. My workers' compensation insurance. carrier & policy no. are:
Cartier" Policy No.
IT . X I k . 2
(This,iection 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
wcirkers'/compensation lawsofCalifornia, and agree that if I should become
subject to the workers' compensation provisions of Sgction 3700 of the Labor
do*db;-i shall forthwith comply with those proylsibind /t
Code;
Oiates,. 17 & d - V ll 'Applicant -
Warning: -Failure to secure Workers' CompeAsation coverage is unlawful and
6hall'subj6ct an :employer to criminal penalties and.civil fines up to *s100,000, in
addition to the cdsfof,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 o . f Building and Safety
for 'a permit subj6ct to the, conditions and restrictions set forth on his
application.:, -: '
person Upon whose behalf this application is made & each p6rson atj
Wk6se request and for whose benefit work is.performed under or pursuant to.
- it issued. L . f I
any permi as a result. of this applicaton agrees to, & shall, indemnify
&,'hdld. harmless the City of La Quinta,-its officers, agents and employees.
12Any, issued as a result of this application becomes null and void if
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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.
f 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
11
construction, and hereby authorize representatives of this City to enter upon
"
4purab6ve-mentioned property for inspectio
the oses.
C4
�Sighature- (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE .VAILUATION..0 TRACT
LOT
JOB SITE
ADDRESS 44-2,15 VIA REL SOL
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
0
VACATION
1423 VIAARL SOL
J b DOKIU.Mcilli K"DAD
LA. QUINTA CA 92253
LUCCRINEVXLLEY CA 92'A,56
0)248-6045 o
(Wx
USE OF PERMIT
POOL ANWOR SP A
P00Li,S,PA-0N"-' - iV.AWSMARRInva 9 ?VAPYr REI PU, AT
FOOL XqTX01Z SPO -k 20,4000..00 L
E—STIMALTED COST Of, WN S T I Z V C T1 VN
PLAN CHECK F -U 101-000-439-.318
COWSTRUC,PYTON M.. 101--0(10-41.°_p11SN) 7. 0 0
hMCflAJN1CJM1TRE, -POOL., 101-00.0 -IM -000 524.00
F,�@ -S '0C), .10.41- 420 000
FRICA , 1, r '000
PLVkffl.1NGrFEE —'POOL,
0
SK(B TULA ,L CONSMOU 110N AND PLANCHECK
LESS RRE41"Aff.)FIEES
124 tod 7 OTUS DUE' NOW
AL PEMN1,11T VC "
FIE4ft.00
1 %
DATE ,by
;1
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
3 z3
Set Backs
Electric Bond
_
3 3
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Und
nderground Plbg. T
00---4
Final
g
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
s Z3maw
Gas Test
Appliances
Final
'
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:
C -
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M
Phoenix Printing & Promotion (760) 240-2317
91-