0012-039 (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. _
ensee #n a tLiic. Class • Exp. Date
jp /^y
,� ,y A. . , lo'�.F� �� ,d,y rb •�!J-NTLI '
Date Signature of, Contractor
t
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).
( ) .l, as, owner of the property, am exclusively contracting with licensed
contractors to construct .the project (Sec. 7044, Business, & Professionals
Code). n
O I am xempf der Section B&P.C."fo� this galon
�,-
Date ' 11. Signature of Ownei "" "" * �l
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of:.the following„declarationsi,
O 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.. .,
O 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-carner &`•policy no. -are`
Cartier - Policy No
STATE PLI14D
(This section need not be completed If the permit valuatlon�is'for $100.00 or less):
( '), _I certify that in the performance of the'work for"Which.this permit is'issued..
I shallnot employ, any person in any manner so as to become subject to the
workers' compensation laws of.California; and agree that*if Lshould become
subject to the w, rkers' compensation proJi`slons of: Section;3700 of the'Labor
Code; I shall fort wl°tf�i comply with,•those ro Ij l I s'
Date: ' �~' �Appllcant`"~^^'-
Warning. Failure to secure Workers' Compensation coverageit.unlawful and
shall -subject an employer to criminal penalties -and civil fines.dp to $1.00 000, in
addition to the cost of compensation,'damages•as provided.for in'Sectlon 3706
of the Labor Code, interest and attorney's fees. `
IMPORTANT Application is hereby made to the Directorof Building and Safety '
for :a , permit .Subject to' ttie'conditions and 'restrictions' set. forth ..on 'his
application.
1. Each- person upon.whbse behalfthis application is made each person at
whose request. and forwhose benefit work is performed unde(:or pursuant to
any permit issued as a result of this applicaton agrees to„'& shall,; indemnify I
& 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, representative's' -of this City-to.e'nter,'upon
the above mentioned property for l inspecti R purposes `
Signature (Owner/Agent) "~ �y Date
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT ��°Z" 3 TRACT
1t2,f 'ice • $�$��HF � - ..
.
JOB SITE
APN
ADDRESS .7..873 Vf A MORMH
OWNER
CONTRACTOR/DESIGNER/ENGINEER
fWMADAY ,AM Gil)&MY
IML Wimryr614 4a V,f CM01b P>~3CiLS
47.065 VIA ARMS ..
9522 D'CsNAL.,Y3SON,RD. .
LAQ'=TA CA 92253
'LVQERW- VAJ` 4 .: , CA 92356
(,160)248.6045 CM#, .4331 .
USE OF PERMIT
POOL A?;%WORi; VA
_
P001BirA ,Al..AR.NISISAMEAS MALI B IN PLA..C*2 A.'Y.f?iifi, P1,AS'TX
R481PEG'i 1014. POOL;, ipmm waOSURE NOT MCLUD-11D.
. Y
i'C3OL ANk71s; R SP ,. 3:#,®i➢li p0 L�
9 TIED C( i P C+LJ i`L1MON
CONSTRLTCTIIO14 RE, '1(1..6064 18-00
MCEiANtCA1,RE' POOL 101Q0e0-421- �2+9,Sin
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70W4' 20-000 .N�iMa
; .x�
_
GYM
TT eL✓�aCpy,gppaFZ7�w,yy�yq /��t7
L�L►> Pool;
YqL119 ,000
.10”
t'}
.127A
r
i.e1f v4{ i Mt' .
.
n•Fw.
L PRE. PAM T 44
$0.0t""!
rTOTA a PERNn"PEZ6 DUE HOW..:.:
RECEIPT%y . DATE /- d � BY D NALE INSPECTOR
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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
Set Hacks
steel
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
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans 7O.K
for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
J
Gas Test
Appliances
Final
� 6�
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)