0303-082 (RPL)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 Exft: Date cv
65 6 1 Z8 C53 HPIC-8 110t41101 -
Date' c Signature of Contractors
A
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).
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 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-fiave and will maintain workers' compensation insurance, as required by
46 -en 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 ST€ TE COMPENSAiTI Policy No. x.046-.¢168-2003 . -•
(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, -1 shall. orth ith comply with those p o islons- "
Date: Applicant���Is:�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fine's 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'sifees.
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 uinta, 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 the above information is'
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authoryze representatives of this City to enter upon
the above-mentioned propWforpectiopu -pois" Date
Signature (Owner/Agent)
BUILDING PERMIT PERMITO.V3-082
DATE FVALUATION;P,. � j9000 'aor LOT � , TRACT
JOB SITE
ADDRESS•0-1490 VM IALA MRA r / /
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
3YlI:F RR, Cri E:1 il<iCC"AT
;lid C&1tiN.Lk P 0iJ,l.,�S SPAS CrOF•y =1 GL
7a-121 1',I.�,EDW—A � 41 00 .
f3�,-1(30 t�VE1J�jT .54
;P.i"•tL,M I: Y1s``1: Wr CA 922,60'
C0A rllMLA CA 92236
(760)398.9222 t 1fr 00355
USE OF PERMIT
001, AND/Ofd. SPA
-
�.r-- RMSIBAR ttEWS O ALL BEN FLACK AT .P€t&PLAVTER INSP CT10A
9 FT, WALL 15.00 LF
POOL, q.ND/ORSP.A . Ik&76.001B
1 g'1x`e ID cosr OT COMS-11 °10H
1,RMO.,*
Pk-JZMf7J; FES tb"MWRY
PLAN io1•1za ris): ."101-000-439-318 S15.4,55
CSONSTRtJf:- ION PEE 1.01 X000.4 a 9-000 $307 00 -
MECi^I,1 NICI LFE9.-- POOL 101-000-421-000 .. $24,00
XLEX, n`:{21f",AL. F' �'I: > POOL 101-0/i}J-d;C�-(3QQ
PLUMUNG Tmz? - P.601A ; ` 1 C3 a�� 1 w� P7.00
• r
. ` ..
MUM PIM-rI FEES
$0100
FFMAR.12�u? PINW MUS IDITE NOW
CITY '
OF LA QUINTG1
FINANCE DEPT,
RECEIPT
DATE; +- -
gY;
»` E F�N D
SPECTOR
'fZI,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
PE
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final,
steel
POOLS - SPAS
BLOCKWALL APPROVALS
Set Berks
,y$ Q S7
Electric Bond
13
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
O
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
Final
Utility Notice (Perm)