0010-097 (RPL)�.r,�LICENSED CONTRACTOR DECLARATION
I Aereby affirm under penalty of perjury that I am licensed under provisions of
C4qpter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, anggy License is in full force and effect.
License # Lia Class Exp. Date
,,,Date t ' Signature of Contractor_ •,
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).
( ) I, as owner of the property, am 6 iclLi§iV6ly cohtracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code): "
O 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. .
M I have and will maintain workers' compensation insurance, as required by
Sebtion 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.
STATF, FUND
(This section need not be completed if the permit valuation is for $100.00 or less)
�O 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' compensatlonjRrovisions)of Sgcfion 3700 of the Labor
Code; I Vall orthwith comply<with thotse provisions.
te: �gT1't ). Applicant
Da
Warning: Failure to secure Workers'• Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civiNines 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 .ori
his
application.
1. Each person upon whose behalf this application is made & each persZt
whose request and for whose benefit work is' performed under or pursudnf,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 srich
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 s.
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of -this City tolenter upon
the above-mentioned property for inspection purposes.
I 1 a ...
$Ignature (Owner/Agent)Pl
`w -- .. _ �- •- ^"" '"' Date
BUILDING PERMIT PERMT/t
DATE- VALUATION. LOT 00.1.0-097 .. TRACT ^
JOBSITE''`
APN
ADDRESS 9
,
47-4 70 VU YLGRENCE
OWNER
CONTRACTOR/DESIGNER/EN (NEER
liryAy k(A�iyJ t�
R�.eFS�, HAWAykg'�f�•�O� R t�ba'�{P�AR.",i���9�`� kPC1�)1,1
q ryc o,� yR Cy�:�V jy�q�t� /
17010 F L' !r¢!:3 4dr. #106
CNY
9521 /1/fiVSai.fL�001.I I=UD
'xUMIN CA. 92780
1;iIMMM VALLEY. Y 0A 92356
(7601)'248-6045 CW. -4 35 .
USE OF PERMIT
P100111 SAND/Op, &$A
11001,,dk,SP.A17NLY.(A:LA:RAr1M..At;1a'IERSt'SHA.L,t,RZ'f'AiPIJ C:EAT 4
frttfC.PIASIPN flKSM-TION, F'001, EQUY.i'PAW'T EN03418UPUR aS NO
114C"I.E3f` ET) iN THIS PERMIT. (1,0 In- t,dMMO.Da) z,
POOL MDJOR SPA 11%909100 LO
EINUM lA M C; O&F 014' C01111M UC71011f
15AX?. O
F, RE SIMMARY
RIAN CHECK FRE 101-000-439-318 2105.11D
1CON;I't'2tUCTiON FEE - 10 f 4=4 18-000 00 $162.00
MZC %A1q MAL RE -- :FOOL 101 -000 -421 -OW Sb4; Q®
FA,=rRICAi.IMS --Pf;301;.; 101400-420-000
Pi,UNM41+ G ne - FOOL 'I ON -000-419-000
t9~
OCT 10.2000.
1: a
. xeFEE
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615
I- LAWins, j
RECEIPT
DATE ° (j f }
SBY p
DATE FINALED L
INSPECTOR
of
00
t - n
U161:2491,90 -MN o.
OPERATION'
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms..& Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Road 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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
Steel
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
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
Appliances
Final
COMMENTS:.
_
r
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)