9606-040 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury, ury, that I am licensed under provisions of
Chapter 9 (commencing With Section,7000) of Division 3 of the ,Business and
I Drofessifz, ,
riakAide'I my � Lic6nse.is in fuil.force and effect.
'X
License # Lic. Class Exp Date
Date Signature of Contractor,,
OWNER—BU ILDEk'61ICLARATION
I hereby affirm under penalty of p&jury that I am exempt from the Contractor's
License Law for the following reason:
1, as owner of the.propertyi,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)..
1, as owner of the property,'. am exclusively contracting
g with licensed
contractors to construct the project (Sec. 7044,.Busine.ss &.'Professionais
Code).
O 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 certifibate of consent to. self -,insure f6r workers'
compensation, as provided for by Section 3700 of the Labor Code,'for the
performance of the work for which this permit is issued.
have and Will - maintain'w6rkers'. compensation. insurance, as required;
by
Section 3700 of the Labor Code, for the performance of the work for. Which this
permit is
,workerscompensation insurance ci�qi�%
My',workers' no. are:
Carrier Policy No.
(This section ,need not be compl6ted if the permit valuation is for $100.00 or less)'.
_1,66riify',that in the performance of the work for whichAhis permit is issued,
`Jshal I knot'le . ploy any'pe . rso . n in anyAanner so,as to,become . subject to the
workers' compensation laws of, California,aand ,,a6ree'vithat if I should become
sbbject to the workers' comperisatic,in-pircivisions ot,�S`6ction 3700 of -the Labor
Code, I 'shall fort iwith comply withthose .provisionst
Date: Le* Ys Ap-Dliclant"-Y
Warning: Failure to secure . Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil, fines up to $160,000, in
addition to the cost of compensation, damages as provided for Section 3706
of the Labor Code, interest and attorney's fees.- J.
IMPORTANT Application is hereby made,to the Director of Building and, Safety
for 6 pe'*rmit Subject to the. 'conditions and 'restrictions: set, forth on his
application.�
1. Each person Upon whos6 behalf this app)ication is made & each 6er§dn 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, indemnity
& hold harmless the City of La Quinta, its officers,* agents and employees.
'2. Any permit issuedas a resuit. of this application becomes, null.pnd void,if
.-work is not commenced within 180 days from date. of issuance of -such
permit, or cessation of work for 1,80 days will subject permit to cancellation.
I certify that I have read this application and state thatithe above information is
correct. I agree.to comply with al I I City, and Statel,el*i`ws' relating:to the building
construction, and hereby authorize,,representati6s of.this City to enter upon
the above-mentioned prop t, in purposes.
Signature (Owner/Age e2`,,6-rv.,,'77/,c Dated f•
PERMIT# :"ONTRQk4
BUILDING PERMIT, 1
9 606-040 3474'
DATE VALUATION . V . . . LOT TRACT
JOB SITE ]APN
ADDRESS 79420VIAS.AIN CLARA
OWNER
CONTRACTOR DESIGNER / ENGINEER
CALIFORNLA.P001S & 9PAS
- '120VIA'SAN 2LAPA
7! 9
41010BOARlYWALk #A2
_Iilki
I,A Q.11AN TAA
M DESEfur CA 92260
(610_00tmo -CUP. 3151
USE OF PERMIT
POOL AND'iok SPA
POOL AM:t SPA
"r P f�
C T 1A 'T OF' ir ST141W
S 1ATED CUS -ON, TOGN
KKK CITE(XIFIFF 1014=439kllg $14DA0
0- 40 $24,
401--00 421 00
PIAINISING VVX3 P001.1 10W)O0419-0N $2710
I
co
CY
I .
1f,JXYIMUC A.1, __.P0(,X. JQJ4)00420000
a
St.f -TOTAL CON91RUCTiON AT -417. PLAINT CHECK
$ST P MDPIEES
$0.01
TMAAL VERIMITYEES DUE. NOW,
S45140
RECEIPT
DATE
DATE F INALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
qn BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
r -Apps & 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 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 -
r
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: