0103-185 (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 # Lic. Class Exp. Date
Date ,` Signature of Contract6r�1"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).
( ) I, as owner of, the property, am exclusively' coritraCting wltn licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&RC. 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
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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify'fhat 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 thF'�21th
ers' compensation provisionstof Section 3700 of the Labor
Code, I shalcomply with tho e'provlsiori5 t�
Date:? l Applicant✓,,---y'',V
. ,Nj -s
Warning: Failure to secure Workers' Compensation coverage is unlawhd -4
shall subject an"employer to criminal penalties and civil fines up to $101 Mh in
addition to the cost of compensation, damages as provided for in Secti 3 6
of the Labor Code, interest and attorney's fees.
IMPORTANT. Application is hereby made to the Director of Building an afe
for a permit subject to the conditions and restrictions set forth hi
application.
1. Each person upon whose behalf this application is made & each p rson
whose request and for whose benefit work is performed under or pur uant. 0
-any permit issued as a result of this applicaton agrees to, & shall, in emnify
& hold harmless the City of La Quinta, its officers, agents and em
2. Any permit issued as a result of this application. becomes null and void if
work is not•°commenced within 180 days from date of issuance of such
permit;or cessation of work for 180 days will subject permit to cancellation.
i•ce fy that I have .read this application and state that the above information is
correct. I agree to comply with all City, and Sate laws relating to the building
construction, and hereby authorize r$presentatives of this City to enter upon
the above-mentioned prope rty�tc�'inspection purposes.
r ' tom
Signature (Owner/Agent ~'" tv _ Dated
BUILDING PERMIT PERMIT#
DATE I VALUATION LOT TRACT rR
JOB SITE
APN
ADDRESS
78-9115VIA FLOIWIMCE
2aiU d4
OWNER
CONTRACTOR/DESIGNER/EN INEER
'.{AID ' .tl-11I.►k BOAT
HAL HAMMON dba IYACA'T10141�00L i
76-il,41
V I Ai FIAO Ui RM,%
522 DONALDrF7O�1� Imo.
F
r5
• �t„� Y./�I.GY
7� jIJL��tIT� J (� R j J
.Lii�V.l.4- 1.V �9A.v�`�.d.'F �Ar�'i3{J
(760;248-6045 MIN 4335
USE OF PERMIT
POt^lir &I SPA ONLY. AL"UM BARIUM aHAU, HE IN PLACE .a T
POOL E:QT,3tP�lf IMT 7CU)BURY, iS NOT
Iri,'YCf.,U13ZU W THIS MWIT.
P001, ANDIOR 9PA 1414
ESTEDINTN) COST 0F. CON,`" ITOMCAN
4�?i€��'l'�'tilOxli?Ai;'&�: if1�.���t�•�FY�4G1�� ."•�i��:ltn
VA ECHA rIrvAI, M -• POOL IM -00". 21-000 $?woo
ZLIXTi3WAL FM -- POOL, 101- 000-42",00
Pf U.N151-PIG MY -- P0,0L �_ lot -000-4191-000 07.00
GsJ D
AR 2 7 2001 ,•
CITY OF LA OUINTA :S'U: +_'T 'i a, COIASTRlYMMI AND PL.t-7 011-RCK..
FINANCE DEPT LFFS3 1 ,;p It
t7•t f3
SOOT''- r d '` .f 7u8 Fs tTSS ?' +'
RECEIPT
DATES
BY
DFNJ D
INSPECTOR
I
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
! 2
Bond Beam
Approval to Cover
r
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
Sewer Connection
Pool Cover
Encapsulation
_ _
000,
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.
Srro_ke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)