0012-030 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed* under der provisions'of --k
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
6 589S, S 4430M -
8C C5 3
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury .that l,am exempt from the Contractor's
License Law for the following reason:
1; as owner of the property, or my -employees with. wages as 'their sole
compensation,• will do'the worki.and the,:structure, is not intended or offered for
Sale (Sec. 7044, Business & Professionals Code).
1, . as owner of the property, am exclusively contracting with 'licensed
contractors . to, construct the project (Sec. 7044,, Business ness & Pr6fes , sionrals
Code)..
I arri. exempt under:Section B&P.6. for this -reason
Date Signature of Owner
.:WORK ERS"COMPENSAT 11 0 N 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 ior'workers'
compensation, as provided for by Section.37Q0 of the Labor'Cocle, -6r,tHe
performance of the work, for w . hich this permit is issued. -
I have
and will' maintain workers'-comp6nsation insurance, as required by
Section 3700 of the Labdr Code, for th6 perforriianc e of the (work for, which this
permit is issued. My workers" compehsation insurance carrier policy, no: are:
r
Carrie' Policy cy No.
"'TAMI - � � ' - � I - -' 'A
S
(This Section need not be completed if the permit valuation, is. for'$1 00.00 or less).
.1 certify that in the p - erformance'of the work for which this permit is issued,
I shall not employ any y person, in any manner so as'to, be6ome,subject to'the
workers'compensation laws of California, and agree that if 1,1should become
subject t _ o t . he workers' cornperisati6ri pi6vislons'of Section -3700 of t hd Labor
Code;l shall forthwith'comply with:those provisions.
Date: Applicant .......
Warning: Failure to seci)re-Wprkers' Compensation coverage is unlawful and
shall subject an employ6rto criminal penalties and civil:fines Up to $106,00, 16
addition tothecost of -compensation, darhages as provided .3766
p vided for in Section
of the Labor Code, interest and attorney's fees.
IMPORTANT App)ication is hereby made to the Dire6tor*64'Building and Safety
for a permit subject. to the condition s and restrictions set forth on his
application.
1. Each person, upon who . se. behalf this application is'made &.each person at -
whose request and for whose benefit work is perfor.med'under or. pursuant 'to - .
any permit issued as a result of ' this ap', plicaton agrees to, & shall, indemnify
& hold. harmless the City of La Quinta, its officers, agents and. employeds.,
2. Any permit issued as a result of this applicEition'.becornds hull and void •if
work is not commenced within 180 days from date of issuance ,.of . such
permit,or cessation of. work for
W9 180 days will subject permit to cancellation;
'
I certify that I have read application and state that the above information is
correct. I agree to comply With all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned ,oropertV for inspection purposes.
Signature (Owner/Agent) E Date
.,
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (0' TRACT
.
12/6=
JOB SITE
APN
ADDRESS
49417 VYVrA PAbObW0
,OWNER
CONTRACTOR/DESIGNER/ENGINEER
T -Di LIRMWMAY aMOPMENT
CAU4X)R1ZA100LS 'a WAS
14 4 75 .001411=044 OA
LA QVIMA. CA 922$3
PALMDESERT CA 192260
(76q)340-19000 C 5386
SU
USE OF PERMIT
IPOOLAMMOTZ*A
ImotivAlBriq 7,31.55- I 995/mRiT, PIT.' ALARMSMARIURKS
.911ALL BPI 1W PLAbE AT'PRZ -PLASTER INSPECTION, POOL ROUIPM91-IT'.
ENCLOVIUV19 Is WYE 'MCLUMD 1114 lfffly PERMIT.
POOL ANDIORSPA. :16,350.0 La
r6" CHECK FEE $)MW
C011STRUCTION F91t
WCHANICAL FM POOL 101-000-421.000
RLYZTMCAL Mr " f'�001' 101;-0 -4.20-000
ARM 110� C())4r,- 11MIMITANIb PILW 01TE OX
$310.00
'33 PF
I X4 E,,PA1D1,TE8
S0100
C1. MES DO
RECEIPT
DATE
I DATE FINALED
INSPECT%
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
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
AW
/ '0
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
l
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:
j
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)