0105-160 (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_ NSipnature of Contractor
OWNER -BUILDER DECL"A
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 contracting 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.
( ) 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:
Cartier 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 an' yRar<'r so as to become subject to the
workers' c • m;ensation laws of C�l�fornla, and, agree that if I should become
subject to eoCode,I ha `�Ith comply with/�? rovisions.
Date; ` Applicant fes,
Warning: Failure to secure Workers' ompen
shall subject an employer to criminal pinalties
addition to the cost of compensation, damages
of the Labor Code, interest and attorney's fees
sation coverage is unlawful and
and civil fines up to $100,000, in
as provided for in Section 3706
rK�f• �,M
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 behalfthisapplication 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 ally and State laws relating to the building
construction, and hereby author' •e representatives of this City td ent r upon
the above-mentioned property f r i spe tion purposes.
P%r •�
Signature (Owner/Agent) Date
PERMIT#
BUILDING PERMIT
DATE VALUATION LOT ��. a-.1�i'i! / TRACT
JOB SITE
APN " • �+ `• w ?
I
ADDRESS I
a '574,
t
OWNER i t
CONTRACTOR EN NEER
VR ttLMS. ITOL 7,
�/DESIGNER
FAuX'OOLS 46671MWCl_tiV
48- 314'bNUx3P. Uf? !vCJ
5"130'•0PXE!1WA.R".RM1 6
LA Q 1WfA CA 9233.';
LA QVID91TA ICA 9225:3
USE OF PERMIT
P{)l' L AND O SIPA
1100J NR°A. ShC,� ANSI 221.59.1995, .Aid".,RA6,Vuy',P.RYFf.'3. MIA1 Y.. BF, 114
�..A•C`3�:ft,°A' 1'iLA=P3..A�7 �1k.1�:APWcA'9'lCadt. !�}CzL:1ll�?Lf3:R'�5lAdi' �;�cyl,�s�f�
NOT MGY.UEII D.
1POM.: XlJ OR SPA A000.00 LS
11L.K" 01EIC K FEE 101.000.439.316 $206,05
0Yk4STRk1C'RJ0N.[ZE 191-000-418-000 $1y1•7.NJ
9. K11H. ANIV.A.L M -- f 00T, 101.000421.000 SUM
Mf:TTRICW,, .FE +- POOL 101-Q00-4.20-000 $45m
MUMBINO Y"¢F:, -• POOL 101-000-419.000 �2�,t9si
�i
, �'CD'r�l?>i., C , :. - IG"1 ie'W •fAt 0 P1 AM t,�.:k11" fes+.
,$ 1 9,05
isuss mmmm Fm
$0100
JUN - 8 2001RM11 • YND19 DITE, VOW
%19105
CITY Of LA 0011NITA
FINANCE DEPT
RECEIPT
DATElfry� /
BY
DATE FINALED
INSPE OF
D
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
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Final
Underground Electric
Underground Plbg. Test
Gas Piping
7L_
( ,�
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®
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:
-
t