0010-171 (RPL)ti xLICENSED CONTRACTOR DECLARATION'
I h m under penalty of perjury that I am licensed" under provisions of
'<' H Chapte69_(commencing with Section 7000) of Division 3 of the Business* and
l< ' Professionals Code, and my License is in full force and effect.
-Date-' Signature of Contractor, '-- f'- ` f
OWNER -BUILDER DECLARATION
I hereby affirm `under penalty of perjurythat. 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 riot intended or offered for
,sale (Se6.•7044, Business & Professionals Code).
as `owner of the property,, am, exclusively'contracting with licensed
contractors to construct the project (Sec:' 7044, Business .& Professionals
Code).
O I amexempt 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, forthe .
performance of the work for which this permit. is issued.
I have and will maintain workers' compensation insurance, as required. by
8e6tion.,3700 ofthe Labor Code, for the performance of the work for which this
permit is issued My workers' compensation insurance carrier, & policy no: are:
Carrier •4`:r' ,Policy No.
STAT.F.FUN f>
(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' compensationlaws of, California, and agree that if I should become
'subject to the workers' compensation,provisions of 'Section 3700 of:the Labor
Code;`I shall forthwith' comply with those provisions,'
Date �' Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful d
shall subject amemployerto criminalpenalties 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
for permitsubject to the conditions. and.`restrictions .set- forth'on• his
application. i
1. Each person upon whose behalf this application is made & each,personat
whose request and for whose benefit work is performed under or pursuant t �`
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 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.*
Signature (Owner/Agent) _ ' W �' Date-/—,, r"�)
PERMIT # '
BUILDING PERMIT
DATE err,, VALUATION , LOT' �_��}^1 TRACT •
1A aD 11.-fnA.M1•C�.iP4J -
JOB SITE j `'
APN 'j
ADDRESS
OWNER- --• . -' -- -
CONTRACTOR/DESIGNER/EN INEER
x.2. DEMXC DF1Vh.T..0PbJf 1'r
3.5001.8 &811AS •. ' � .'s
R0, BOX 1716
7-4-)25 J�C.'.CT1.:6;rR.'( X #
bA Q7.3;NTA CA 9225.E
...
)"ALM DwWr CA 92260.
u
(760040-9000 000 C7 -4f 355-
.557USE
USEOF PERMIT
PODIA, PA08DQ 1121.E 1991 ALARNISA?AiMlrl`4S hIUS " BE Na PLACE
AT 1 Rr;,,•x ;~.r,'!,STFR WORMY POOL. 1�QUIP1�F 141 ISNOT FCOS.4,FO.ED M
'THIa.;t, 3
S PE
POOL Al'MOR SPA DO 12
RjsX��IM Fy>.�yyq MMMARY
(�1.'g
B�I.df:N cSilgcrF:. it1' y !!pp\ nn op { ryry
�1.i'^`��iICJ`�l' / *1t(,m
,.+.7
101-000-418-000 $189.I0
� .•, i'
f , ,*
.CONS71:iCfYii-FOR
gdS7i, FRITY Pool, 420.
,
Emu. w. '€? Jt �a. 2 `d �:1-i UCi 2iD G(20 $45.00
T''LLsiMB140 FSE -- PWL 101.000.419.000
b�'tf .its AL C°K��i�1'l�'i6w�T!(��' v��5� ��iat�� C:��LC1iC
$4. A35 ` ^;
IMS ]PER -PAW" ..
$0.00 • ;
It VE HOW
OCT.2.6.2000 '
AT
RECEIPT
DATE
.BY" N , i �f
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
Electric Bond
Footings
Main Drain
/
Bond Beam
Approval to Cover
Equipment Location
Electric
Underground
Underground Plbg. Test
_
Final
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
Gas Piping
ioG
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Loan Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)