0206-124 (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
,ra5ffi1
C53 IRC C-$ 1W5110a
Date rfl !` Signature of Contract�of9P
OWNER -BUILDER DECLARATION s,
I hereby affirm under penalty of perjury that I am exempt froni 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 affirmynder 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
S�'cfion 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 ET T.P. CLOMPERw'. Tal Policy No. 0460006168M
(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 Sect on 3700 of the Labor
Code, I Shall fo .hwith comply with tlios�e provisions.
Date. f=•Applicant—
W4�,,
uv
*Warning: Failure to secure Workers' Compensatiorfcoverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, it
addition to the cost of compensation, damages as provided for in Section 370E
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
application.
1. Each person upon whose behalf this application is made & each;person al
whose request and for whose benefit work is performed under or pursuant tc
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 it
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 upor
the above-mentioned prope for inspection purpos s.
Signature (Owner/Agent) oda. �� Date 1 ` •
PERMIT #
BUILDINJG PERMIT
DATE} ALeUATIOtJ`-Awawnw LOT TRACT
JOB SITE
ADDRESS 484" WSTA NiC►AhMA.ULA APN }
OWNER CONTRACTOR / DESIGNER / EN (NEER
MOM- - .00C D..EVM# ,d.'i'P� ..'' f`:AL* ...TR1gL1,,P0' 01,3 & SI M CMP
?, 1A.qmu CA 92153 1?AU4 DL."na "f CA 92260
r SS�3'��b0=9ZI0�3 � .00355
USE OF PERMIT.
POOL JS.1-VIVOR SPA
NOT INCLUDED,
VALUATION
6
22,000.00 1U3
BUD Hia!MM co Yr 010
CONSTRUCTION CTION FEE 101-000-419-000 $x15.00
MECHANICAL VZ& -- POOL 101.000.421.000 $24.00
P.LR.MUay.AL 1% E -- r.?OOL 101,•000-420000 4145.08
P1,t3MUtdi7F EE -. M)L 16-000-41V-000 $2100
3k
D �.t i fI) &3� Y���C�TAL:W.C.1w
[i=t1 U t SSS ME-VADM.
,iU V 1 1C11lZ
1.y1 ~RTIFE.,,; DUtt NOW
CITYOF LA UINTA
IN
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
POOLS - SPAS
steel •
Set Backs
Electric Bond
Footings
Main Drain 9
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test _ .- e,
Final
Gas Piping
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 g
Gas Piping
Gas Test
Appliances
Final
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: