0210-098 (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
o.56126 C531411C C: /i 1U Ir. .
Date/C �� �' Signature of Contractor ly '`R`
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
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.
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 'STAPFE tr`074l1RENRATI Policy No. D4,60006163-02
(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' compensationrprovisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: �`� ?,yJ! �.aApplicant/Frf/s../ 1Iy
�.
,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 Section 3706
of the Labor Code, interest and attorney's fees. g
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
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, agent's 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 i
construction, and hereby authorize ze representatives of this City to enter upon
the above-mentioned property for inspection purposes .r
Signature (Owner/Agent) Date'"'
' :ti y3l': s ✓"
BUILDING PERMIT PERMIT#
DATE VALUATION $2. LOT ��•1�Q� it TRACT
JOB SITE APN
ADDRESS 48^445 VISM CAUCO -
OWNER CONTRACTOR / DESIGNER / EN (NEER
TD 33ESEM IYE LOial UNT d;.FrLwl9t;tliiCaaxOf.;!fz & :�"Frt`ts croi> mps CC).
PO BOX 1716 86- M AWN•6 E 54
LA QDDTXA.. Cly. 92253 COAC1'"k27J..A. C,A 92 236
(760)498.9222 03Vt 00,M.
USE OF PERMIT
11MIL.P MYOR 81'
POC)]., SPA, FIREPIT T (496ACW 16 LF. S' e.#=41if aEN W LI. CITY
SM, 1�J ><RM511I111 itT F3s A E�IAI�x• 13n1 Pi.�1t`I .� }` :P K•P �1's` ?3i
T4ISPLCTION.U1PNX1- 1 T fMC1,03AJPJHNO'd MIC1 t DF0.7
SFT, . W,z7r.A ,
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EgrEl i.Aln"D COKE OF 4' ONIRRUCr:I:ION
PEWIT FER M)".LY�MNRY
PIAN C;1ITK ME 101.000.4.39-339 51�3.f,0
MECHA111CA)d FLOE - POOL I01-000.471.000 SROD
E1•,'EC1'10 CAL f RIR " POOH. 101-00 0-420-000 $45,00
PLUMNO FEE POOL 101 -6300,419 -not) W.00
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IMF)_'M. TAAL C01+1�', RUC I O9 AND PL &I T CIECK -4-92.10
LEM MIE-PAW PERS S0,00
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CITY OF LA ®UINTA
FINANCE DEPT-
RECEIPT DATE BY DATE FINALED INSPECT
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
:2
Set Backs
Electric Bond
3_®Z
Footings, ,/ —p
Main Drain
j—OZ
Bond Beam
Approval to Cover
-
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
J
PLUMBING APPROVALS
Gas Test
Electric Final
1
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
_
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
s
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)
COMMENTS: