0105-158 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby,aifikm under penalty of perjury that I am licensed under provisions of
mmencing with Section 7006) bf Division 3 of the. Busin6iss'and
Prd,&Si6iials C*ode, and my License is in full force and effect.
440940 0&30ru
signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
`' property, ' employees with wages
oomo6noaUon.will dothe work, and the structure ionot intended moffered for
sale <Goo.7o44. Business & Professionals Code . '
( ) |, as owner of the property, am exclusively onmmming with licensed
oommcmm to construct the pn4vm (Sec. 7044. Business u Professionals
Code). '
(> |amoxomp underSection omPC�«no`�maovn_______
Date' ' Signature o/ Owner '
)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under
penalty of perjury one mthe following declarations:
(e)ll have and will maintain a certificate of consent to self -insure for workers'
pompensation, as provided for by Section 3700 of the Labor Code, for the
perfo rmance of the work for which this perm.it is issued
I'have and will maintain workers' compensation insurance, as required by'
section 3700 of the Labor Code, for the pi�_rformance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. ate:
Carrier Polity No.
lan
(This section need not be completed if the permit valuation is foe $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
w6rxo,s'compensation laws ofCalifornia, and agree that if should become
subject to the workers'. compensation provisions of Section 3700 of the Labor
Code, -I shall forthwith comply with tho �.p)ovision(..
Warning: Failure to secure Workers"'Compensation 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.
/MamTmv/ A�m�nm����mmom��m�/m/�and S�� '~
for a permsubject m the conditions and �o�oUono m� forthgapplication.ms~_application. '
' behalf this application s made moao» person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued ooaresult ofthis apPicamnagrees to, & shall, indemnify
& xo|U xann|mm the City o/ La quinxu, im.o#|oers, agents and employees./
' o. Any permit issued aoa result u,this application becomes null and void i/
work is not commenced' *umn 180 days from data of ioouonoo of such
ponnit, or cessation ofwork for 1*0 days will ombjom permit to cancellation.
|oemfy that | have read this application and state that the above information io
correct. | agree vocomply With an City, and State laws relating mthe byKding
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Sio�t.re (Owner/Agent) el Date
BUILDING PERMIT
DATE VALUATION LOT TRACT
64
JOB SITE
APN
ADDRESS
I
OWNER
CONTRACTOR DESIGNER / ENGINEER
St
48-644 VInAPALANNO
:57,-61 G.Molunumi.,
A.A. Q(.YW.A CA MS3
LA QUIMA CA 92253
(76q564 -1e.37 MAX 6453
USE OF PERMIT
BE IN PLACF-4Y
Pool, ANT90a SPA IS
X&TGVWVE1D COST OF C-ONFINUC-31014
4,9,M).00
MVINHANICAL FEE e. Pool. 101-000-421-00%) $24.00
XLECTRIr4&L "All .. POOL 101-000-42,04100 $415.00
PLUMBAHO FEE -- POOL 101 -000-1. 19;1000 $"100
PLAII my PIC, K. ME $240.99
CINONY911C 101-M,418-000 $401.
('0145TRU $0
MAY .14 2001
CITY OF LA�QUINTA
Ar RFD;
RECEIPT [INA1,111pb
BY
DATE FINALED
INSPECTOR,
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE tNSPECTOR
BUILDING APPROVALS. MECHANICAL APPROVALS
,t 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
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final s„
Waste Lines Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans OX for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final 1,2 —,)v
— 3
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.
Smoke Detectors
Temp. Use of Power .
Final
Utility Notice (Perm)