0010-217 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapterrsr{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
X516128' 3 J Oki IAU
Dater. Signature of Contractor»-- T
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 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 not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 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.
W,sr3T3F•CW:`? t?d45-i►e�fli/ljlCfti l+ .
(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 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 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 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
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 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) """Ms _ "i Date
BUILDING PERMIT. PERMT#
DAT '. VALUATION LOT IjrIFA %i f TRACT
ItJ'1* � 1
JOB SITE'
APN
ADDRESS
4"47 VIi IA,PA:L(YfXO
-
OWNER
CONTRACTOR / DESIGNER / EN &NEER
111.0 D%. 13E'i/ELa. PUEM.'
C:A1<70R1QkP00LFJ Vit. STW
TO Bt.X 1716
74-/25 JO1UDRIVE, #A
T.A. QUIRNUA CA 922.13.,
PAUIDESITU
CA 92260
355
USE OF PERMIT
POOL A. SPA. t`}NI��.1��.�`�iv''i?r9 �9�aAt�+cFy1�.�;S1•R..A,LL i1F n4 PLACE AT PIS
fVN0TFR.rHJ9 ' a10H,PO MEQUIPMEUs .WCU)SURR 10'l OT MC;LY1DE6
IN `I'H} S P�1 VIT
POOL .6aN17/OR SPA I"Woo
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�•yy,, gg �o�ryry,. �yy' ,��ii //��ppqqQ,,��p'��yg�t� y�I�]?.,`siXi€�KC.W
PLAH 011MC1a i? $111.15
R".C}NSY`ItiMCTIs: *N n-119 101 _013K. -•d J 8-000 $171-04
MWIR&MCAL VICE -• POOL 1131.000-42100
FIZEC;TPICAL FE"tp N POOL ' 101-0410•-420-000 �� W.00
Plo'11,1101110 PUB ^- POOL 101-000-4 19-000
OCT23
2000 ,
QUItAT
am TOTAL C:ON&I.'AXIMIONMi:P:tAMCilw'.
$4,78.39 fr:
IMS M -W10 P-W10FF `S
i$0.00
RECEIPT
DATE �'BY,
yt��••"" _
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Steel
Electric Bond
Main DrainZ
Approval to Cover
Equipment Location
_
i
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas.Piping
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
/
Gas Test
Appliances
Final
0 -
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)