0201-099 (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
C53 I'l1�`�8 ' �1 M/()i
/Date � ; , ' _ � � Signature of Contracto,� d �
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 -off ered 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 ii issued. My, workers' compensation insurance carrier & policy no. are:
Carrier, Policy No. `>
STATS i0Mi'I TINA I i3A •6 0006163
(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 I should become
subject -to the workers' compensation provisions of Section, 3700 of the Labor
Code, shall forthwith comply with se pro lislons.
Date Applicant ✓ =• t
Warning: Failure to secure Workers' Compensatidn coverage is unlawful and
'shall subjedVan employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for{ in Section
of the Labor Code, interest and attorney's fees.
F
IMPORTANT Application is hereby made to the Director of Building and S Wat
for a permit subject to the conditions and restrictions set forth .on
application.
1. Each person upon whose behalf this applicatiomis made & each pers
whose request and for whose benefit work is performed under or pursua t to
any permit issued as a result of this applicaton agrees to, & shall, indem '
& 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.
/403
}
Signature (Owner/Agent) / 3 4p-' /- AWDat
BUILDING PERMIT PERMTN '
DATE VALUATION LOTTRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN (NEER
a). DE.�iZ.T M:mi a C. 1.Ixm_ - i;h,i�
P,' 3. ,BOX ??'116 '74; 25 JORT 7.7MVF, SWI`i? 4A
LA QMITfA CA 92253 P.lY1JA LTISER VIA. 912."50
(760)340m9000 Mi'l 03,55
USE OF PERMIT
-POOL ANT)/OR VA
SPA.A.6:.At:M:'e/8A1;Mkf.JwS SK/U4,139 IN Pt.ACE.4T PR&I''LASTEIR
1N,SPW14014. 11004. WXIa':Iv PIWT EWC1,aI3URX NOT 9401,[FI7 D,
POOL-AYdDJOR SPA.
-40fava 1Z
EMMMM COST OF CON911Z.UCTIOn 70w- P01
PLAN CHECK FEE.
CON'MRi:TION 1JIM'101-00
0-4
18-000
ari+0.Aa1i-AJ.,.qX "" Poqp; 101 -0004M rOl 00 M^�BQ,tNti)l
113I'�+FRE P0,9f7 'ID?'a0 1 i9aG }G w3.�3D
'
JAN 11 2002
A"YOTLA °
!°F Yp5 sCuWIRT;IaR SLs &iM . .
TUM, "Fiffr VMS DUE QW V4450
t.
NSPECTOR
RECEIPT DATE
j /{) BY,�,f}{\_: DATE FINALED I
' j
INSPECTION RECORD
OPERATION
DATE
I '.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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. 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
Gas Test
Appliances
Final /-2—
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lary Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: