0011-279 (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
✓:fit, y 4430/02 -
Date Signature of,Contractor " }
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury.that l,arn.exempt from the Contractor's
License Law for the'follow'ing reason:
( .) -1, 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).
( ) 1, 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
V hereby affirm under penalty of .perjury• one of'the' following declarations--
I(,
eclarations:(, ). ( 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 whicfi this permit is issued.
(
I ) have and will' maintain workers' coinperisation 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. '
STATE FUND`
(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 any manner so as. to become subject to the
workers' compensation laws of California, and agree that if] should become
subject to the workers' compensation provisions of Sectiori 3700 of the Laboi
Code; Is hall forthwith'comply with_those provisions: '
Date: ApplicantWarning:.. Failure to secure Workers' Compensation coverage: is unlawful and
shall subject an employer to criminal penalties and civil fines:up to $100'00.0, in
addition.to the cost of compensation,damages as provided for'in Section 3706
of the Labor Code, interest.and attorneys fees. '
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 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 applicaton agrees to, & shall, indemnify.
& hold harmless the City.of.La Quints, 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 all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
r� t -
Signature, (Owner/Agent) Date 2 ' t'
BUILDING PERMIT PERMIT#
DATE/''\./ VALUATION_, _ .LOT F�SDS }:°' - TRACT '
J�
4
JOB SITE _t
APN
ADDRESS 48-45 % „
OWNER
CONTRACTOR/DESIGNER/ENGINEER
P,01 BOX 141716
74-725 YO@71 DRIVIT, 4A
I.A QUID A Cls. 592253. J
PA L M DE. RT. Cdr 9.2260
538E
USE bFPERMIT
POO -J, $LMJR L{s3 _
Pt DIA,1.A. I A►tUML+<sR7d1Lf2� sk3'Au tip IN Pl R.CL AT PRZ- %P..CU T�.�2.
xf~ SPEC k'ION, POOL, EQUi•PMMT:DITCLOSISR 18 NOT 10l.+t•1�.��i�.
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pool, t'►ND1Ot'SPA )..1
`n Ji wdL' �,�!^' •i:.r�4d;YdIPW Ww$�M1�I'dQ. ..
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Y.`AS,.lX1Tl� LJC,E &D hI KAR -
PLAN CHPOK FEE 101 x,000.439.1. 18 gt rl, is
CONSTRUCTION FEE 101-000-418.000 �R'1i.nG
14"UCHAAiIi'�(�L FM -•;FOCI, .' 101-000.421-QQO
PIATNIDTitiO F',ER ..- POOL . I Y14Lt 4 k 9-;000 UO
`
SUB-I'MAL Cti d! YNIXTUTI1'?N A9.0 PI.MW CHEC":k�:
Wall
MAL FFSMITI 0S NOW
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Footings
Electric Bond
Main Drain
�p
TJ
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
_
7
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
v�
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
Fir '
Uf (Perm)