0012-201 (RPL)LICENSED CONTRACTOR DECLARATION
I jiereaffirm under penalty of perjury that I am licensed under provisions of
Chapter 91commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and rry Lice is in full force and effect,.,
License# Lic..Class Exp. Date p'q
•~ f•w .C7 'Gt' ' .r -+.n. .,., jam,/ �,S.r^, ^•, '
Date' Signature of Contractor w
OWNER -BUILDER DECLARATION
I. hereby affirm under penalty of perjury ttiaf I -am exempt from the Contractor's
License Law for the following reason:,
as owner, of the property, or my employees with wages as theii-sole
compensation, will do the work, and the structure is not intended or'offered for
sale (Sec. 7044, Busin ess`&'Professionals Code).
( ) 1, as 'owner of- the property, am exclusively',contracting with licensed
contractors to'consfruct the .project (Sec. - 7044, , Busine`ss & Professionals
Code): c
O I am exempt under Section B&P.C. for`thisreason
Date Signature of -Owner'
WORKER'S COMPENSATION "DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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:
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.:
STATE FUND 1�7+6$t3d�4f3
(This.section need not be completed if the permit valuation is for $100.00 or,lesO:
(. ): 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 tabor
Code; I shall forthwith comply with: those provisions:
Date: 'f 4 Applicant
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 Sect'ion,3706
of the Labor Code, interest and attorney's fees.."
IMPORTANT Application)s°hereby made to the Director of Building and Safety
for :a permit .subject to :the conditions 'arid 're'strictions'set, forth-, on' his'
application.*. y.
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 comrrienced'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 Piave read this application and state that the above information is
correct. l 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.'
Si nature (Owner/A nt)• Date
BUILDING PERMIT PERMIT#
DATE�yVALUATION LOT f� TRACT
JOB SITE
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
74 -
'M J0141 DRIVE, 0A
CA 9225:3
DE."r T CA 12260
396
(7OO)340.9000 CHO 5396-
USE OF PERMIT
USE
POOL, A17DIOR. EPA
f 06L,,%'5PA&(1) FaF Q&(J) FIRE -PIT (Ats,sIZ21591MI)
CiAFI>R';t'-.ALAR.M.498A.ff,RIPR3 5%1AM BE IN PLAX9AT PRE PLA.97'M
1)44 Pi+t;T!t?N. OOL EQUi<t'1MJ{NT ZRf.".1,03U'r{.Z13 NUr INCLUDED M THIS,
POOL V1 DIOR SMA 14
XYTIMAMD cosrr Off+ C.OMMUC'l.:ld 24.
PJ�AN CMECK MER' 101,0004394418
CGHSTRUCTION FEE 101 -C00 -41R -W-40 �J�o.cto
MWHANIOAL F11% L 101 -000 -4.21, -OW
ELIMTRICAL P79 — POOL. 0.1
DOO MOO
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` sL.m-If0IW el"1,,11.0 ' "D P11AN' (141-YRICK
..DEC 2.6' 20 � a • .
RECEIPT
DATE
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
Alf 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
a
d
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
000,
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
Gas Piping
Pool Cover
Encapsulationp
ZD
Gas Test
Appliances
Final
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)