0012-036 (RPL)LICENSED CONTRACTOR DECLARATION..
I hereby affirm under penalty of perjury that I am. licensed under, provisions of
Chapter'9 (commehcing'with Section 7000) of -Division 3 of the Business and
Professionals Code, and my License is in full force and effect, - '
a License # Lic. Class Exp. Date
3b ✓3f
Date ��' ` Signature of Contractor I �-
OWN ER-BUILDER'DECLARATION
I herebyaffirmunder 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)., ;
( ) •-1, .as -owner of, theproperty, am exclusively contracting with licensed
contractors to construct the project (Sec. •7044, Business & Professionals
Code). dd
O'I am.ezemtt-under.SecUon B&P.C.:60this reas' n �^
Date . 1 Signature, of OwnBr �= ! '.K f
WORKER'S COMPENSATION.DECLARATION
I hereby. affirm under penalty,_of-perjury one of the, .foil -owing •declarations:
O I have and will maintain a.certificate of consent to self -insure for workers'.
compensation;, as providedfor by Section` 3700.,of the Labor Code for the
performance of the work for which this,permit is issued '
( .) I have and wills maintain"workers''compensatior ,insurance, as required by
Section 3700 of the, Labor Code, for the perforriiance.of the work forwhich this
permit is issued. My workers' -:compensation insurance •carrier & policy no are:
Carrier Policy No
ate."-+
'
.ATE- U14D : ti 229 W►. 9n1S+ 9
(This section need not be completed If the permit valuation is for $100.00 or less):
(: `)�-Vicertify 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 subje9f to'the
workers' compensaUon,laws °Of California, --and agree that•if I should become
subject to the workers''compe'nsation provisions,of Section•3700-of the Labor
Code;1. haf fo hwrth comply with those provisl ns:
Date Applicant't'tR
Warning: Failure;to securesWorkers' Compensation cove'age Is unlawful and
shall subject an employer to criminal pena(fies and:civil fines up to $1'00,'60 ' 0, in
addition to the cost of compensation damages as provided for in Section 706
of the Labor Code, interest and attorney's fees `.
IMPORTANT Application, is hereby made tothe Director of BuildingIand Safety
for a permit subject. to. *the ;conddions+.and . restrictions set forth on his
application, .
1. Each person upon whose befialf,this'application is made & each person at
_`.`whose request:and for whose benefit work is performed under'or pursuant to
any permit issued'as a result of this applicaton agrees to, "&; shall, indemnify
& hold harmless the, C-ity,of. La Quinta•,. its officers, agents and employees:
2. Any•permit issued as a,result of'.this application becomes null and'void;'if
work is not commenced' within 180 -days from - date' of'issuance'.of•sucli
permit, or cessation of work for 180 days,will subject permit to cancellation:
I certify that I have read Phis application and -state that the above information is
correct.. I.agree to -comply with all City,`and: State laws relating to the, building
construction; and hereby authorize represehhatives�of`this City to enter -:upon
the above mentioned property for'inspeGtion'purposes
Signature (Owner/Agent.)------1 t I 'bite" ~w�
7.
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BUILDING PERMIT PERM TN
DATE VALUATION -LOT' 00124W,) TRACT
JOB SITE
APN
ADDRESS q O8�tq� VYA r/ W
OWNER
CONTRACTOR -ft ENGINEER
C. �r � y }e�z�c
11 � O� dibs
9527WONAU W=,
LA QUftJiA CK 92253
USE OF PERMIT _
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INSP3.C'* 1014. POOL RQUIPMEHY NKC141SURLR3OT rRICLUDRID,.
Ft7OL ANDJOR SPA • . 1 Qn9 l LS., .
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PLA CHECK FEE. 101-000 43031$ �t }' .: 4359.30
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CC31J RiJK:`E�CfM PUP, t$d5-1kt�.���i1�vOt7fJ. �Fd,s'.Sti:
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RECEIPT -,Y�
DATA cel
BY
D IN
INSPECTOR
l.�
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
r a �—
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
�%el. ez
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)