0108-306 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) )f Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
A56128 C53 Date Signature of Contractorv
, ,/i 'fin•".
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).
(r) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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.
, I have and will maintain workers' compensation insurance, as required by
Sion 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.
r
(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' compensation provisions of Section 3700 of the Labor
Code,'I hall orthwith comply with thIZ provisions. �
,� w
Date: � Applicant a, ca�'� Jo n
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 LabonCode, 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 o
application.
1. Each person upon whose behalf this application is made & each pert
whose request and for whose benefit work is performed under or pursu
any permit issued as a result of this applicaton agrees to, & shall, Inde if
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and id: i
work is not commenced within 180 days from date of issuance'of uch !
* permit, or cessation of work for 180 days will subject permit to cancel)
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 property S jinspection purp set.
Signature (Owner/Agent) % �r Date
V BUILDING PERMIT PERMIT#
DATE VALUATION A LOT. 01:2&W6 TRACT
82 1.9 ' 00
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
P.0181041-1 1716
d ` 725 JON! DRA A74.+M AA
LA, , QU;i NTA CA, 92253
PALM. DEWERT CA :92260
(160)140r:000 G'Bvi 355
USE OF PERMIT
P00112�fd�A
PL OUPA. Asia!k:''A4S&R.3'�1�,��,K.'5 5l'dril,.lk..'i.4•E IN PLACEAT PU1 PIASTER.
ft3pp'�CTION, X'00b i3QUIPM'.919T ENCLR?WILE; XOT INCL,fIMD.
1'��C3)r,t AL3t'{�1a atiA y.ar
E& 1,TndA1XI), !0b7 00 CON19L A3=074
21,00i?A)
PLAN CI LCx1;.ZF 101.-000.439-318 $140AD
COM.11TR.1:1{;i`ION' FEE I 0 000.419-M
MECHANICAL AN -- P001, 101-000-421-000 MOO
I;i.3';ty TRICA.L FIRM, —1POOL 101-000-420-000 $15.00
''I.,11mCSl7uf4 mil - PoOL 101.000,43Rz+t100•
e
! TAL(bf3%Yai'rx*��%DC"I flAT.t�t�F '3.A,id 0-16��,T,�
$45140
UG 3 0 2001 L)RUS MR -PAID
.1$10100
r
ITY OF.IA QUINTA ItYlVi!sLPER M. 1f P'IK'E D10.1111 NOW
FINANCE DEPT.
RECEIPT
DATEp
-'Cy 9
BY j
1�,�'f
DATE FINALED
INSPECTOR
1
T
LIO
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
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric '
Lx0
Underground Plbg. Test
Final
Gas Piping
L/
PLUMBING APPROVALS
Gas Test
Electric Final
Waite Lines
Heater Final
Wier Piping
Plumbing Final
Plifnbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pcle
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)