0404-063 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 co Professionals Code, and my License is in full force and effect.
C) License.. t Lip. lass Exp. Date,
or- CY � C 0445 F f3 c. t: �� k40/04
r; W
�i
o OZ r- , ✓Date � � ( Signature of Contractor
CID _
J U OWNER -BUILDER DECLARATION
LV W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ ID_ License Law for the following reason:
Z ( ) 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
LO
N Date Signature of Owner
ON
rn
d< WORKER'S COMPENSATION DECLARATION
'It � I hereby affirm under penalty of perjury one of the following declarations:
LO
FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
Q QSection 3700 of the Labor Code, for the performance of the work for which this
IlLO L Z permit ig3iA s; d. �My�w�orkers' compensation insurance c��e�� & pfolicy no. are:
Carrier Policy No.
Cb �5-y
V
Q (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 prow ions of Section 3700 of the Labor
Code, I all/o_rthwsit� comply with t e rovisi 44ns�
'Date: ` [a �i i Applicant. ,'zo.-, �'..- --•.
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
any permit issued as a result of this applicaton agrees to, & shall, indemn ,
& 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 vol I
work'is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellati n.
I certify that I have read this application and state that the above informatio is
• correct. I agree to comply with all City, and State laws relating to the buildi g
construction, and hereby authorize representatives of this City to enter upon
the above-mi entioned propertAfor inspection purposes.
j
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT0N0061
DATE / _ VALUATION 1.vilrjf#•f LOT 95 TRACT .
JOB SITE :?LTJ-; 7ci��i:.
APN - -
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
i3.J`r DgVi1ZI-,NiIYln. , lNe.
Iurwt1�S"raLam, Jac
3 A Z5 E, M VIW-f TY DRIVE
1.415 E. UN'IVEM!'r- Y D.P I F-;
P1.01MI X Az 8503M
PHO - i AZ 85023 :
(602)257.1656 MUM 4990
USE NFi.JCI
POO
P,t^', a Fa P, A-1%F'C 7 7 _0i 19 At e!�'�%APrA'&FF
/�'1'q F'�p Cift AlKtl 4'A'!
PLACE PRIOR TO i REPLAS ['ieR n4,c R CTICK
POOL AND/OR SPA MOM" LB
EM31!: ATED CON"r OF CC}MMUCTI4: N,
PERMIT IMP SUMIAiLkY
Tw�N C1:3ECKI FLEE 101=E000.439.318 $105,30
COINSTkUCTION! PLC I01-000.418.000 $161.00
11+SEM ANIM, s Z -. POOL 1131.000-421.000 $24.00
SLIXTI i6:AL FE8 •- POOL 101-000-420-000 $45.00
PI.L`IME3TNO FRE -- POOL 10) -000.419.000 $27.00
:3%xf.',-•TC'TAL C ON .1•t.Liiw'i' ON MD FI..A"M CHECK
$363.30
LESS PRE -PAT 1WO
$0.00
. I '�'CiTA , �'":1��::1ti23r: YMESs �J'tl:�:.C�4.iW
9 .`30
APR 66 2004
CITY OF I -A. QU€N.-rA
FINANCE DEPT.
RECEIPT
DATE/
BYDATE
FINNAsLED
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
Steel
� –
Set Backs
Electric Bond
Footings
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
5- Jd L75
Gas Piping
Gas Test
Appliances
Final
—
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)