0011-097 (RPL)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty ofperjury that | um licensed under provisions of
^- (commencing with Section 7O0)o(Division oo/the Business and
Professionals Code, and myLioonooio in,un��oand omo�.
uoonoow � uo.c/auo Exp. Date
'
656148
[13
' Date Signature of Contractor
OWNER-� .
136ERDECLARATlON '
| hereby affirm under | �ofperjury that |anoxomptymmthe 'Contractor's
uoenoo Law for the following reason: `
( ) 1, as owner of the propen�ormyemployees with wages as their sole
compensation, will Uothe work, and the mmou,o is not intended o,offered for
sale (Sac.7n*4.avoinem&Professionals Coue).
(�) |, as owner ««the Property, am oxovawnly contracting with licensed
contmomm to construct the p,Na6t,(oon. 7044, ouammm u Professionals
Code).
()|amaxompunder Section __�.ouPc.for this reaoon___�____�
Date Signature of Owner
WORKER'S COMPENSATION. DECLARATION'
I hereby affirm under penalty of perjury bne 'of the following declarations.'
.1 have. and will maintainla 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;
I have and will maintain wor�ers' compensation insurance, as required by
s6ction 3700 of the Labor Code, for the performance oi the work for which this
permit is issued. My workers' compensation insurance carrier & Policy no.'6re:
Carrier Policy No.
V., AXE FUND
(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' perso - n in any manner so as Jo become subject to thd
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions, of Section 3�OO. of �the Labor
Code, I shall,forthwith comply w ith those provisions .
:Warning: Failure to secure'Workers' Compensation cove i rage 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.
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
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 permi . t 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
permit, or cessation of work for 180 days will subject permit to cancellation.
dertify that I have read this application and state that the above information is
correct. I agree to co,mply'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.
BUILDING PERMIT
DATE VALUATION LOT' 001.1-07 TRACT V
3.
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER EN&INEER
T-10DOX. 1716
LAQUNTI-L CA 92253
PALM DFSKXr CA 92260
Q60)340-9000 C.BLO 355
USE OF PERMIT
IN THASPEWIT.
PWLANDIORSPA La
nmw= cos
C014STRUCT4011 ME 101-000-418-000 $171.00
101-000-420-000 $4 5. 00
PLUMBINGFER POOL 101 -0001-419-000 SZ400
OUB -TOTAL CaNTIRUM.101.q PLAN CHEM
so. 6b
RECEIPT
BY-,
DATE FINALED
INSPECTOR
INSPECTION RECORD
1 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
Final
Underground Plbg. Test
Gas Piping
Q ��
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final�_O(
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
„ J
Low Voltage Wiring —
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)