0106-065 (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
196
Date! Signature of Contractor
OWNER -BUILDER DECLA ATION
j -tier by affirm under penalty of perjury that I am xempt 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 '
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, 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
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.
9TA iZ 'FUND 1244912411
(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 wor • for which this permit is issued,
I shall not employ any person in any rnpnher,so as to become subject to the
worker ' compensation laws of Galifornla;'and gree that if I should become
subject Oto th° workers' compensation�prvisions of Section 3700 of the Labor
Code I,gfiall�grtgwith comply with tnVPE% vi�iorls:
WarningtFa{lure to secure Workers' Comrhsati n 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 .
of'the Labor Code, interest and attorney's fees. • .
IMPORTANT Application is hereby made to the Director of Building and•'Safety y
for a permit subject to the conditions and restrictions set forth on hist' r
application. JV:
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 result of this applicators 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 wito all City, and State laws relating to the building
construction, and hereby author' lfepresentatives of this City to enter pon
the above mentioned prope or inspection purposes.
A,
Signature_„(Qwner/Agent) �_ `` " Date
r.... q....- .... �•..r .
BUILDING PERMIT PERMIT#
DATE. VALUATION LOT, Q�Q� Q y;6j TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
48--N47 `V&'n,AFKJ.0MFt1T0
53300 AVM)AR"flRH7,
I,%Quft ..A. CA 92,251
LA QXrlihi'S'P•a CA 5223:4
USE OF PERMIT
P001, Pi5V fCal ,SPA
POOL ,_af?ds CYNL , rlMMIT VOKS 140T fNCL Dee, HLO K VY.AI,4 ALAR=S'
All tUQUIRWTO S.K l`��STALL,90 NUOR TO mSPF.C'f!b)34
P001, AND/OR SPA I's
ENTZIATED COU OF, COK9-MUMION
210M.00
PERMIT FEE 90MRARY
PIAN C31F X. la
WS'g'RUC''r10W ME �a C2 S �tlOfi-tb Y �-�3SD(3 $ GQ"I: iA
WYD,HMI..Cr;41T .NO, — F<Ob 101000-421--IDOO $24XO
zL,Vt1**rPJQkLF1F,V, — POOL -000-4120-000
ty� t
JUN
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CITY GF Ln_UGiNTA
Fl;l;}r�Cc,DENf
RECEIPT
DATE ; *—"""`
By
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
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
_
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Final
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: