0010-096 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chap e. 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
Signature of Contractor 4 ;i
%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:
( ) 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 'ot the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 70,44, 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
Sec ion 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:
Cartier Policy No.
STATE I±'UND d;tA•129-Iii�1�b;�3
(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 t6the„
workers' compensation laws of California, and agree that if I should become:
subject to th workers' compensationtprovisiions �Of Section"3 00 of. the Labors �
Code, I shall hwith comply with those proulsio-
i�Date:% Applicant ""Z' . j t i.
Warning: Failure to secure Workers' 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 f
of the Labor Code, interest and attorney's fees. 3'
IMPORTANT Application, is hereby made to ther.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 yesult 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 4.
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatiKes of this City to .enter upon
the`above-mentioned property for inspection tipurposes.�
q Signature (Owner/Agent) ``"'N �' f t• Date i a'
V v 4
.BUILDING PERMIT PERMT#
DATE F VALUATION LOT Rli�a� 4�! TRACT
`
JOB SITE ; -
APN
ADDRESS
47-440 VIA 111ORNKNCE
OWNER `
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CONTRACTOR/DESIGNER/EN (NEER
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. d'LL"t7.,�I'.'.1,Ala LiJS�I ba p.A.{.w.AMAR .ICia'tJ S
i160�2 �f€ CMIJO 43K)
USE OF PERMIT
F, � 011 1". IV -JR. HPA
POOL & :SAA ONLY, x� 1,�sf'�MSJL'P.E�,R1Ll S :3tt�.�:. "B� 1�v�C� i►7`
PR19-1sLhfJTFK WS1yt ,t';°f IOW, POOL EQUIPMENT EN4:i!:.OPOU ,E 10 WO
Xl3tr;I„ UDKI) PN THIS ?!yUMI t . (LOT 123: 2+4M 444ODZI.,)
POOL ANWOR SPA I V".00.1.3
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ES11 Y,�A`s,.Y D COY O W.S�J.'( ' V S.rf..aO
PLAN Cl i�:tr rw" �'1:C� 101-On0.439-Y) 8 $100.30
6ONS`!`Ry,;CTION ME, .1011000-418-000'' �ISd.dldJ
KKMANICA. I.%`RE •• 3'00L 411.000421.000 $24,0
1"00L .. 101-000 -420 -OW sokm
PLUW1k1114t;# 1 tF �-Ff1r3i, 1 'i -000.419-100
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SUB`I�`}'.f�I,CC3�Ja'�i1'�alt�'1;tt�N AHT�,?f�1:e�1v CHECK
La3 I'M
'$x'0,017
.PR1%'.••PAM
PAI U_
UMILMM"r "ETS DOE NOW
-. �OCT,10
'2000
Iry
RECEIPT
DATE
BY,,
DATF.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 Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Bond Beam
Main Drain
Approval to Cover
Equipment Location
/
Underground Electric
Underground Plbg. Test
Final
Gas Piping
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
Gas Test
r,5x.-7
Appliances
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)
Final�•J
COMMENTS: