0101-160 (RPL)LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed Under provisions of
1-- 6hapter 9 (commencing with Section 7000) of Division 3 of the Business and
(n Professionals Code, and my License is in full force and effect.
C) ,License # Lic. Class Exp. Date
'LX fwwtqv�e -Y If
r— I.— C:) OWNER -BUILDER DECLARATION
LLJ LLj r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason;
Z ( ) 1, 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 the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
I am exempt -under Section B&P.C. for this reason
LO
N cidte Signature of Owner
< WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
— F-; 0 ),:,1':�ave and will maintain a certificate of consent to self -insure for workers'
X UJ �: compensation, as provided for by Section 3700 of the Labor Code, for the
n _J _J performance of the work. for which this permit is issued.
< 0 have and will maintain workers' compensation insurance, as required by
0 Sectioh'�700 of the Labor Code, for the performance of the work for which this
13� issued. My workers' compensation insurance carrier & policy no.'are:
permi is
arrier Policy No.
!.f -:'(This section need not be completed if the permit valuation is for $100.00 or less).
_J 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 cornply witht�i ose provisions.
Warning: Failure to s_�cure Workers' Comp(,A�tion coverage is unla ul an;�',
shall subject an employer to criminal penalties and civil fines up to $10.0,000, 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 a nd Safety
for a permit subject to the' conditions and restrictions set forth on his
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
pdrmit, 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 agre; to comply with all City, and'State laws relating to the building
c ' truction, and hereby authorize representatives of this City to enter upon
thd above-mentioned property for inspection purposes.
Signature (Owner/Agent) Dat6. /Z 41
74T�,r
BUILDING PERMIT
DATE VALUATION LOT TRACT
11
ADDRESS
OWNER
CONTRACTOR DESIGNER EN61NEER
PUBIOX Y716
'74 -725 JONI DIME, HA
(760)340-9000 CSIR 5386
USE OF PERMIT
RZ
ELFTRIlaAL Ir 101-0 $45.00
PIAITVIBINO RZ POOL 101 A419-000 $27,00
61 Zoo
17 V
I= M_Jp" 11EF3
MOD
BY
DATE FI
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS t
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 Firewair
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Z
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool CoverJ—
_
Sewer Connection
Encapsulation
g
Gas Piping
Gas Test
Appliances
Final
a
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)