0303-127 (RPL)y..\.'.
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I 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 Exp. Date
raj 4t51 L53 9/30,103
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 (�)� Ihhave andwilly ainta nwhichork for workers' compensation issued.ermit is
o pensation insurance, as required kiy
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 SITA.TE FUND Policy No. . 046.02 010467 '
(This section need not be completed if the permit, valuation is for $100.00 or. less).
O 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 shalllforthwith comply with those.provisions..
ate: Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000 "
addition to the cost of compensatiori, damages as provided for in Section 3
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Sa
for .a permit subject to the conditions and restrictions set forth on
application.
1. Each person upon whose behalf this application is made & each persof at
whose request and for whose benefit work is performed under or`..pursuanjLo
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 and state that theEabove 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 inspectionipurposes.
Signature (Owner/Agent) /�"Date'
' BUILDING PERMIT PERM':}
f . -
DATE VALUATION��� LOT i TRACT
3
JOB SITE
ADDRESS 80460 VV TAias MA
APN
OWNER
CONTRACTOR/ DESIGNER / EN &NEER
73-) 21 RRRi 3 WAKING 0.100 `
P101 BOX 1793 ;
�'li1.M.1;PT:M,�i' CA 0+226Cf
:C.A.QLTa'�d:m CA 9225_,
(760)300.3585 M4 194.5
USE OF PERMIT
0QJ )/C13 VA. .
INSPECTION, EQUii'itr.EXT I/NCt�c3M,ENOT INCLUDED
POOLAAlWOR SPA ;L,'"
. �1�d.ilYdCc�.6.�.7�Gr4dN:A, `��is •\r Wl�A7 etJGG+J 4+A.6WJ.9
l.:J�4/Etd/e1u*V
PIAN CHICK WE 101.000.439.318. $105.30
CONST'Au 'f'IC1N
Md:C:JARrYvG�AL FEE -- POOL .101-000421-000.
it
PI,i7MDR40 F)RE •=,POOL. ; ' 101.000F419.000 577.00
Li
MaR 11 2003
CITU ik'I LA QUIN SIX TAL'.00Ne E UCUOIT'A _.'T7P:CM.dMC
�3G�i.3Q
F;NANC'.E DEPT. F, ' U33 PP.l{-P.� W I �
$0,00
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RECEIPT
DATE;
SPECTOR
1(
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - PAS
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
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
Fina
Utility N (Penn)