0303-159 (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 ' w Exp. Date
310111 C t7 C 5 3 1XC 7/31/0
S• f, • ., a,�.,.._..
bate 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 selMnsure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
p rformance of the work for which this permit is issued.
( I have and will maintain workers' compensation insurance, as required by
Se tion 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 i TAY9 FUND Policy No. . 170939.01
(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, I shall forthwith comply with those provisions.p•�^''""
•D'a'te: k " t,.r , ,,� s Applicant - �a�
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 to
any permit issued as a result of this applicator 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 issuanceof 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 authorize representatives of this City to: enter upon
the above-mentioned property for inspection purposes. -
i)h
✓ Signature (Owner/Agent) - --^ - !*• Date . I '"
PERMIT# ,-
B' jLDING.�PERMIT.
DATE LOT " ' : TRACT
f'VALUATION
JOB SITE
80-505VlA.7.'. LA VR
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN &NEER
T011,131 O TI -3n_ z WC
UIM3�..f2.;t MUFS P001S, INC
842;M#.TEL'{.�,,'1.. ,
18.078 CfBtMTkY C3. Ub DR, ;� E, 206
];AQC�.+11A CA X253
BERWIDAD•F NF ;' CA 92211
)345.4601 C13
USE OF PERMIT
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tKL.C• Ri AL PPIr,. POOL 1.01-000-420-000.
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S0100
MAR •1'4- 2003.
ClTy '7�' L p quINTA
RECEIPT
DATE:
BY r 7 E
I ECTOR
INSPECTION RECORD
OPERATION I DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION 1 DATE —1 INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Condensate Lines
Final I I
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 , a
PLUMBING APPROVALS
EaoTesttric al
Waste Lines
Heater Final
„Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
1111.1 -.
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
t.