0312-182 (RPL)LICENSED CONTRACTOR DECLARATION . _
I hereby affirm under penalty of perjury that I am licensed under t;rovisif4 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
483 498 B C53
-2.7
DateJ-.r 57 '—,Signature of Contractor_
sr- �/FP
OWNER -BUILDER DECLARATION
12/31102
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 insurahce carrier & policy no. are:
Carrier STATE FUND Policy No. 16=30-02
(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, I- shall forthwith�gomply with those provision .
/Date: r' P` p'plicant 7'_/ 6 I •.f-^ �. '�` """q
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth -on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi It work is not commenced within 180 days from date of issuance of s 2.l
permit, or cessation of work for 180 days will subject permit to cance'llati
I certify that I have read this application and state that the above informatio s
correct. I agree to comply with all City, and State laws relating to the buil Ing
construction, and hereby authorize representatives of this City to enter u on
the above-mentioned property
�for
r*inspection purposes. !
Signature (Owner/Agent) ,---,.,Date
DATE
BUILDING PER
PERMIT#
LOT - IN%12.-182 TRACT
JOB SITE APN
ADDRESS 13;3--175 V.VA eitJ.:fMOS
OWNER CONTRACTOR / DESIGNER / EN (NEER
'MVI BRI31:03 P3;lRR1+1✓0.7' )C%.,;3 ,AND CONIMMUM: 014
80«37 5 'VIA VAL OSA P.O. BOX. 152.4
LA Q11:t A C.A. MS 3 PALM 13L SERI T CA 92261
C?60)56$-4963 e,"8V/ 72.5
USE OF PERMIT
POOL A?3IXOP. WA.
P001.ESPA. '.A.L,r'iRM.dYiL3ARRtY;G S S#I1 LL BE 114 PL AC K AT WIZZ-PLAS'lTFUZ
YNSPECTIOX. EQUIPMENT ENC 1,05 IPUR NOT 1W.'GUD E D
P001, ANO/02 SPA
1S.(Il0,00 L,5
WrIVA.'MD COST OF t;CC3NSTRUC.'lif€3N
15,0W.00
namff FEE SITK~V
PLAN C YIECK FEE
1.01-000,439-318
%J05130
CONSTRUC:TCG.H FEE
)u1_000�418-000
163.00
WCHAN)CM, FEE •- :POOL
101-000-4.21-000
$24.00
0i'a.CTTICAL, FEE .• P001,
201-000-420-000
Kuwl 3T1JC.:f ,i%'ER _'_ POOL
`101.000-419.000
�2Y,SIil
TUB-�SY,YiAL COMMUCITON AND PU:1T C1•lWIC $1363.30
LE"m w"Y� AmFV's $0,00
(� '3:'fJ'FAL YEIltiRT n7h'3 S DUE POW
DEC 3 0 1003
CITY OF LA
GgEE_: v�it.t: 0FPT. DATE^ I �, -, !f BY�� ` ( DATE. FINALED I INSPECTOR
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
Steel
POOLS - SPAS
Set Backs
footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
Gas Test
Appliances
Final
;Final
dlity 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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OF LA {�UINTA G
-Nwr, R. SAFETY DEPT. .