0304-112 (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 $ of the Business and -
Professionals Code, and my License is I,n full force and effect.-
License
ffect'License # Lic. Class Exp. Date
65612 3 C33 VTC C-8 10/31/21.'
Date �/' /A 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 thd''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 1.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one, of the folio ing declarations:
O I have and wi0maintain 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 have and will maintain workers' compensation insurance, as required by
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 STATE COMPERS.f1.'1'1 Policy No.
(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 tJhJ'gse provisions.Aq
Date: t� /1-S Applicant—
t provisions.,
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 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 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.
Signature (Owner/Agent) 1�/ A /1 4:,1 Date
T
BUILDING PERMIT PERMT#
0304-319::
DATE 4{t•/ VALUATION' ` . LOT TRACT
JOB SITE ` p
ADDRESS^# �,w`.1Hi i.iwA6tl
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
TC>U.19YtMIii? S INC.('ALD
-,
RNIA POOL.9 A
9PAS (TOP MAX CC
7 � 1 1 t I des 1Ci i 1 C1t7
86� 100 A qUE 5t ` :.
P.ALMDIRS.l?AT CA 512260
MACTM111A
CA. 92236
(760),598
00355
USE OF PERMIT
POOL A` DICIR SPA.
3t;.'PdT.tE''13►'OU2�a,1�,.3'ld
POOL ANIXOR SPA D,C*0.00 L3
ESIXIMf TIM COST OF CCaN1iIMUCTI:C?N
PrRvur rm ffnoa `
MAN C31PCiY h" ;1< 101-000-439-318 ffi9S. Y0
CONS9'id.UC'd ION 31'EE 161-000-418-000 MOO '
L?;>r1 G3'RMAL TEF° .. POOL 1 01400-420�000.
PLUJ!H3I*H r;?fX,-�P00L 101-000419.000
T ,
.DEQ
APR 14 2003
CITY OF LA QUINTA
..FINANCE.pEPT
SUB -'1.`4' TA:LCO .:�.. i
Lr.Z3 PPYR-PAM PM
$0.00
?I'MAL PKIRMT FEMS VOL NOW
RECEIPT
DATE f
BY+ %FI
INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
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
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
Plu ing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances `
Final
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:
'
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