9802-021 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that l 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 rt' Exp. Date
656128 C53 10!31198
Date` I r 'f' 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:
( ) 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.
BUILDING PERMIT
DATE VALUATION LOT
PERMIT #
�tYU'Ic-UI�- TRACT
JOB SITE APN
ADDRESS
78-€360 VIA M Ei,ODIA
OWNER CONTRACTOR/DESIGNER/ENGINEER
T.D. DEVELOPMENT
79.795 PLANCRO LA. QUrrA. ISR
LA QUINTA CA 92253
USE OF PERMIT
P0 01L AND SPA.
POOL A ND/0111 SNA.
CAL1FOFRNIA MDLS & SPAS
74-725 JONI DRIVE, #A
PALM DESERT CA 92260
(760)340,4M C.EL# 355
16,0(1).00 LS
3TXfE FUNDf rytE,-98.006168
ST C T OFC(3NSf 1'RUC11ON
GCTA
1.6.000.00
(This section need not be completed if the permit valuation is for $100.00 or less).
$��l �,� SUA1A[tKRY
() I certify that in the performance of the work for which this permit is issued,
rPLAN
CHECKFa, 101-000-439-318 $1
1 shall not employ any person in any manner, so as to become subject to the
workers' compensation laws of California, andAagree/that if I should become
CONSTMUC 1iON F EG 101-000A18-000 8171 !0roe
subject to the workers' compensation prow, isions o fSection 3760 of the Labor
NECHA N1 1Ct\ L.-� POOL 101-000-42,1-W $24.00
b "
Code, I=shall forthwith comply with those/provlsloJns.1:ECT{21CA�t.
f ' `"Applicant %�
FEF -- Pf30L 101-000-420-000 $4S_f)t}
z
Date: fir_ �' /
PLUMBING FEB -- POOL 141-000-419-000 $27.00
rn �
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
O�
addition to the cost of compensation, damages as provided for in Section 3706
_!
of the Labor Code, interest and attorney's fees.
ILL
IMPORTANT Application is hereby made to the Director of Building and Safety
LLJ
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
C)
whose request and for whose benefit work is performed under or pursuant to
an permit issued as a result of this a licaton agrees to, & shall, indemnify Y P PP 9
SUB -TOTAL GONSCRUGl'Iv1`I AND PLAN CHECK
5378. i s
& hold harmless the City of La Quinta, its officers, agents and employees.
Lt SS PRE -PAID FEESU.(',:'.
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 ill subject permit to cancellation.
TOTAL. PERMIT FE F.% DUE NOW
5378.15
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.
( , % ,�K
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RECEIPT D TE
`�" 9
BY /
�(
DATE FINALED
INSPECTOR
Signature (Owner/Agent) ' f Date ! /
f
.Air
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forma & Footings
Ducts
Slab 6r6de
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 Wali 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 — (h
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
a G 37—
Gas Test
G
Appliances
/l
Final l/f
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)
COMMENTS:
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