9706-075 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of .perjury that I am licensed under provisions of i
Chapter 9 (commencing with\Section 7000) of Division 3of the Business and
It Profess�nals Code, and my. License is in full force and effect. j
License # Lic. Class Exp: Date 1
617723 A -w, '' b .b
Date Signature of Contractor
OWNER -BUILDER
I hereby affirm under penalty of perju1y,thaVl am exempt from the Contractor's
License Law for the following reason:
J ) 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
( ) F 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.
( ) .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 carrier & policy no. are:
Cartier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
I certify that in the performance of the wofor which this permit is issued,
I `shall not employ any person in any manne so as}o become subjerct to the
workers' compensation laws of California /and agree-that`if Ishoultl become
-ate Y V
subject to the workers' compensation provisions of Section.•3700 of theorab ro
Code, 11 shall-forthwathcomply with lho�se pcovls�ons %7r�%%
Warning: Failure to secure Workers' Compensatiori eoverage is unlawful and
shall subject an employer to criminal penalties andcivilfines up. to $100,000, in
addition to the cost of compensation„damages as providec!16 in Section 3706
of the Labor Code, interest and attor`ney'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
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, 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 applicatii
correct. I agree to comply with all Ci
construction, and hereby authorize i
/he above-mentioned property fff or ins
ignature (Owner/Agent) !
and state that the above information is
and .State laws relating to the building
resentatives of this City,to enter upon
� f
tion pu�o:se
s. D/
at* -
,
• BUILDING PERMIT PEFiMTk °°NTR°`#
�7 5335
LOT TRACT
DATE 011/9' VALUATION ss,-moo
JOB SITE
ADDRESS 79-200i{.�Ii r.4�:M C
7
OWNER
CONTRACTOR DESIGNER /ENGIINEER
qy Q l )) A 1 i iJAirl e4iAlsl
RfM (ALBU7M” c.s.
7 .2ttti `1� I%i L#`s`C' C•
39685 9r. 261 iC",I i' AE1., PLACE
LA C?1?1NMA CA, 9'1253
PA,(..m. r)Hs r C:A, 92260
(760)345-fv116 +151.5
USE OF PERMIT
POOL
POOL 0-KilY
TOOL JVIN QIP; R SPA 8,5E ).00 L3
KAN (.'HEO' FPJ 101-000-439-318 $7020
CONIS`. RLIC".ITUN VVE 101-000-118-000 SHM. -M
f Lr-0R1CA4.1<'GL -- POC,1L 101-000) 12"'00 r S15.w
a�1,.zii,03iNC iut, �<x�3� 101�idClO P �2'i.F10
O . . .
JUN 12 1997
f
SUN,TA
;[r}Gf, � Cly,.
$250.20
LESS PRE -PMD Tiifi5
$0.00..
TOT A1,1'EWna_iYa
20
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
t
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
CK to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
� POOLS - SP S
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)Q
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
i
Z Final
,Utllity Notice (Perm)
COMMENTS:
D
(%R
.CITY OF LA QUINTA
SUB -LIST
CONTRACTO ✓c ComADDRESS �U
OWNE ' n JOB ADDRESS
This form shall be'oosted on the iob wth the Building Insoection Card at all times: in a conspicuous place:
It is the responsibility of the General Contractor'or the Owner/Builder to monitor -fie sub -contractors 'that
are on this list are the same. persons performing the work. Any, changes to this list must be approved the a
City of La Quinta Department of Building & Safetyrh for to --work being performed by a changed sub-
contractor. Failure to comply will result in a stoppage of work,and/or the voidance of building pefmit.
GRADE/._
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C-36
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C-20'
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POOLS
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