0103-181 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under povisions 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. Dat;
6361Z.8 C., rC: I/w,
Date V'"•� ` '^r� Signature of Contractor
p,
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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt u er Section B&RC. 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. * .
I have and will maintain workers' compensation insurance, as required by
Ce tion 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.
STAT COMPENUATI aJ4S+J 6D.T
(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 worker�,compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply wit hose provisions.
Date: " '?`� • Applicant"
Warning: Failure to secure Workers' Coirnpens.Von coverage is unlawf I
shall subject an employer to`criminal penalties and civil fines up to $100,
addition to the cost of compensation, damages as provided for in Sectio 06
Of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby'made to the Director of Building and §afety
for a permit subject to .the conditions and restrictions set forth oLonat
application.
1. Each person upon whose behalf this application is made & each per
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2.'Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit,. or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prope for inspection purposes.
Signature (Owner/Agent _ ✓ Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT CIMS -451. TRACT
&1`1 SMAKA 60
JOB SITE`
APN
ADDRESS
OWNER
J ;
CONTRACTOR/DESIGNER/EN (NEER
`
�S' 1VR 1 11 4ikr'LO��3'i�i1s F1i'
G'' �1�FO.E MA POOLS & AS i Ol) MA i (10
F D" PMY 1',71 G
14725 JO;1 U DJR1VZ X'ME AA,
1A QVRrrA f OA, 92255
PA1MI E'.�ER1' Off. 92260
(760)340-6MOO CDT*.
USE OF PERMIT
T�L�i3f,d�.t'E�0l:3ar4 w.�..1iSX ti�'P«�3-.ISI33. �,C.�T;:�+�A,X+`.i:1�ftS SX•t?:LL T;3'�;
1'OCtL E.�T?T"r'1t4K f a
LeNCL0,3RE 'NOT IRt f.,L1D9>D.
P001,AN DIOR SPA 21,$Koo L-0
,i.
11*1MWOr FMEt: 9TABU RY
PLAN Cr1'3.WK PC, 1x: > 101-000-439J 18 V46135
CC3tJ.`'; RUCTIC N M� 101-000-4,18-00€1 $225.00
MECH,€341W, 799 -- POOL 01-000.,421-000 S.M.00
ELECTRICAL CTRICAL. Vt9a .- POOL 101-000-4,20-10,00 $45.00
0 1.;�1 P.M -
T.. o. 101-000.419.000 $27.04
MAR 2 3 2001 .r
CITY OF LA OUINTA
FINANCE DEPT
SUB -TOTAL C'01 � °Ckr 'c�°�'IC� a3I A �?�'Ai Off. +'.} .
$467.21
LEM PRR-PAM FUM
U), 00
-167 S
t.
RECEIPT `
DATE
BY<� ' !i
DATE FINALED
INSPECTOR
<Z":"
�3,�
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Bond Beam
Final
Electric Bond_
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
,/All 4�/
/y
_
PLUMBING APPROVALS
Gas Test
Electric Final
Heater Final
I(2
r -
Waste Lines
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
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)