0104-279 (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
656128 C15.3 IM 10;
_ ap 10 .
Date c, Signature of Contractq
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).
( ) 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:
( ) 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.
e�* I have and will maintain workers' compensation insurance, as required by
ction 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.
(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 shall forthwith comply with tho941provisions.. „
Date:—x Applicant %ar b
1714 _f
�n. ,
Warning: Failure to secure Workers' Compensati n 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 Sec I06
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building a ty
for a permit subject to the conditions and restrictions set fortn is
application.
1. Each person upon whose behalf this application is made & each son t
whose request and for whose benefit work is performed under or p rsuant o
any permit issued as a result of this applicaton agrees to, & shall, i demnify
& hold harmless the City of La Quinta, its officers, agents and en iployees.
2. Any permit issued as a result of this application becomes null a
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 property for inspection purposes.
Signature (Owner/Agent) ` 0 + I� n Date »V
BUILDING PERMIT PERMIT #
DATE VALUATION LOT 0104'-.2 F_ TRACT
JOB SITE
APN
ADDRESS 48- e IRRIA&A
-
OWNER
CONTRACTOR / DESIGNER / EN INEER
P.O. BOX. 171 0
747 2:5 3C19 DRPJ:lzs, SU117 HA
L,fs.Ql~i:L,rXA. C!A 922.53
RALMD.'�47'LR CA 92260
(760)340-9000 cRu' l, 355
USE OF PERMIT
POOL AND/OR SPA
Pof,7.WPA. XAe,.2tVS;BA1tRBF3nS SHALL 131; iN PLACE AT 1'dtA: P1.AS'`F1 Z
POr;3Z,oAIdT, OR SPA 13
M:eM IC M, OF 4.rONaBHEHUCITO.L*V
22,A) 18O
PERMIT FET ISUMMAMI
MAN 1W -K r+'I I
MKCHAINICAL FV. t&- POOL 101000�421-000 $X06
fT` '1'I;. CA.L lFEaZV, —POOL 101-000-420-000 $45-0
PLT4f.AK3KH(J #RAZ-- 1 000 -`• 101-000-419-000 VIM
,PR 2 6 2001
�:IS S ' :} � .i.. C°C>�3';�J°°1' tit'E""1`.i0m, P�t�S'l.� �?T..:W 0-�t CK
f�;. g
.I`T9 P1MPIAIl rM41)
(3't30
CITY OF LA OUINTA
FINANCE DEPT
TO IAL PEUMIJ, FEE DUE iMW
:1
RECEIPT
DATE 1
BY
DATE FINALED
INSPECTOR t
�r �
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
POOLS - SPAS
Footings
Main Drain
_
Bond Beam
Approval to Cover
Equipment Location
_
Underground Electric
Underground Plbg. Test-(
— — —
/
Final
Gas Piping
.y
PLUMBING APPROVALS
Gas Test
Electric Final
T_
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
Finan
Qr�
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
,
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
b.
Main Service
Sub PaAels
Exterioi Receptacles
G. F.I.
Smoiie Detectors
Temp. Use of Power
Final
Utility Notice (Perm)