0403-417 (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 Exp. Date
419309 C27 C53 12/31/01
Date ' I L r Signature of Contractor { °-
OWNER-BUILDEWDECLARATION
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 exempf'under Section , B&P.C. for this reason
Date-
'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 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 Policy No.
S TA.° 1 MMID 614360
(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.
Date: 1 `= " ADDlicant ' . * _� I I :--"f U '' :- ' f
Warning: Failure to secure Workers' Compensation coverage is unlawful and
DATE LOT fr403.4.1, 7 TRACT
shall subject an employer to criminal penalties and civil fines up to $100,000, in
JOB SITE
ADDRESS I
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
OWNER
IMPORTANT Application is hereby made to the Director of Building and Safety
SAY 1. PTOIt
for a permit subject to the conditions and restrictions set forth on his
78915 $Jt1Mifi SM,
application.
LA. TA CA ?2253
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
USE OF PERMIT
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.
PREPI,ASTER lNu!'EW."0014,
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
1010MOD
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. ,
k_
Signature (Owner/Agent)' �' Date
CONIMZU'C:1110N MBD PLAN C"'1_iFC1C.
$289.05
T711-11JUL?
7Ji433 : 'REL-M1O
$0.00
Lim\ "3'arAL 1-'• iR AI.T FEES DU .'. NOW
MO 1
ILDING PERMIT PERMIT#
JFVALU`ION
DATE LOT fr403.4.1, 7 TRACT
JOB SITE
ADDRESS I
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SAY 1. PTOIt
L7MR-T PA,IUMI fir KDOL8 t&, ISPIAS
78915 $Jt1Mifi SM,
104 (WAS LOS M7S033
LA. TA CA ?2253
RANC`.f:.10 VllkMOR Cm's 92170
(Y60)83,6 03o CUk. 4090
USE OF PERMIT
JA00LrriMOR, SMS.
S SIL ONVT. t�f+ t AA a �tELtP.22.S :SHALL ''09 IM PI,�AC) PPJOk TO
PREPI,ASTER lNu!'EW."0014,
1't'O ANTNOR SPA 4kx 0 +fi.JaJ Ix
EsTn"T D :,'CSS"" , OF c:014181=101C.111off
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Pim CHECK PRIX 101 <ODO-439-318 $76.05
CONS't`RUCT!O?d PYLE 101-000-418-000 $117.00
Wv`HANICAL•FEF -•POOL 101.000-421.000 S24,00
Z11ECTRICAL FL•P' .. POg:f, 101-0301424-000 $415.0x7
P3. UM$13 O 1811, -- POOL 10-1-0100-419-000 $17X9
CONIMZU'C:1110N MBD PLAN C"'1_iFC1C.
$289.05
T711-11JUL?
7Ji433 : 'REL-M1O
$0.00
Lim\ "3'arAL 1-'• iR AI.T FEES DU .'. NOW
;£l_S .05
f :AR' 312004 /
RECEIPT"DATE
frINAEJCE jjl ]'
.
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BY f f /
DA E F ALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR OPERATION
I DATE
I 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 POOLS - P S
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
hAte
Lines Heater Final
ter Piping Plumbing Final
' elumbing Top Out Equipment Enclosure
Shower Pans O.K. for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final �g
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)