9709-083 (RPL)\ LICENSED CONTRACTOR DECLARATION
UX hereby affirm under penalty of perjury that I am licensed under provisions of
`- Chapter 9 (commencing with Section 7000) of Division 3 OLPae Business and
C14 U) CLI . ,��fProfessionals Code, and my License Is in full force and a act.
, M License # - LicClass Exp. Date _
C) �r- 0� ll r trig"d s . )
UJ
CC l
oZ ate Signature of Contractor t 1�
m O' I
JC) � OWNER -BUILDER DECLARATION
HUj I'hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
p 2 z I hereby affirm under penalty of perjury one of the following declarations:
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 � Q performance of the work for which this permit is issued.
C0 Q U ( ) I have and will maintain workers' compensation insurance, as required by
Q C) Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier u ,: , : Policy No. 3 -- j^,
J (This section need not be completed if the pe valuation is for $100.00 or less).
( )' I certify that in the performance of work for which this permit is issued,
I shall not employ any person in a�,tmanner so as to become subject to the
workers' corppen ation laws oj4alflornia; and agree that if I should become
3 subject#to t w rk� ompen1 X pr u}is�;on`s tof Section 3700 of the Labor
�C de, f,sha f�rt v5i h mply wit��tlpl'6visi�ns.
te:1 V Aplicant i
Warning: Failur to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
for a permit subject to the conditions and restrictions set forth on his i
application.
1. Each person upon whose behalf this application is made & each person a�
whose request and for whose benefit work is performed under or pursuant t0
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application d s'"fate that the above information is
• correct. I agree to comply with all yD' , and State laws relating to the building
construction; and hereby aut ofi -e representatives of this City to ent r u • o
the above-mentioned propefo`r ins ection purposes.
t� f 7
Signature (OwnedAgent)r Date
BUILDING PERMIT PERMITM °°N59 27
DATE f / ^ VALUATION S5 �I01)(1-011 LOT TRACT
JOB SITE %V%.0%N t„l.cl.HCA
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ROCKY & 18.' INIF T•.i,Ti. T A.
T XAML'Y POOLS CO NS": RUIC';'10N
79-i 10 VIA SAN CTaARA.
53300 A,W-NID.A, RAMI LEZ
LA QUIY`r A 9C 210153
T.ri 0 U f N" rA CA 9Q253
(7641))%.4.3655 C'AT,.T; M3
-
USE OF PERMIT
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VOCAL AMX0P,3P*A I's
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1PLAN 048C1, 1 16Arg I.ITl.U
q�.AF3, ." =. Al1 -01 �0^61G9 T1 _000 )NN^�faf5�AL d
V.LECTR K-11YVI FEE — K r+. 1 (?042()- OO rs4 .+f0
t3Ll.fA:��ts�Tc3l�Rr�s l�t;,p�'ik. Ti).i-J,�(p�aT��4J�3a �r";,fDt)
8 lRVTiIt' , to- ON4T.HLIQMICV AND PI AN t.T Jft'CT`:.
CITU ®FLA , . r")R'.r.� N" FEES
QUINTA
x:(),00
WMA$., 6 6 .14 ? , 'S 0141,NOW
OCT 01 1997
FINANCE DEPT
RECEIPT
DATE
BY �/r
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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
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
7M,
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
- Cj
Final
Utiiity 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)
COMMENTS: