0104-296 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I arr. 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.
Licen 6 # Y Lic. Class Exp. Date
,Ddte Signature of Contractor-,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 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:_'.___.
N04) J have' and will maintain workers' compensation insurance asre . q , uired by
S6cl(pn 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 r I Policy No.
Alf?, 0010KHOW I
(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-shal I of employ any person in any manner so as to become subject to the
work 2-11
pirs-
, compensation laws of California, and agree that if I should become
sufect to the workers' compensation provisions of Section 3700 of the Labor
C de,,I, shall forthwith comply with tfi se pro rsigns,
I -1;11 . . ? 6�
Applicant—
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 cosi of compensation, damages as provided for in Section 3706
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 at.
whose requbst 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
cons4uction, and hereby authorize representatives of this City to enter upon
Ir
the/above-mentioned propertyeT inspection purposes
)
ISJg'nature (Owner/Ageht) Date
BUILDING PERMIT PERMIT #
DATE VALUATION LOT TRACT
ie) $29,0WM
I H In - 1 106
JOB SITE APN
ADDRESS
SYTISMA YSM"WA
OWNER Ye, CONTRACTOR EN INFER
Ir.D • JAMP MZT DEVELOPM M." C,.AJ.JF0RMA,P01,X8 & 811AS �TOP MANT 001
RG, BOX 1736 74735 J0241 DMMSUITS 0A
CIA 92233 PALM Tri- CA 92260
CY60)340-9000 CBLO 355
USE OF PERMIT
POOL KtUXOR. SPA
1NSiYJMT1M11 POOL MQUIPHFNT KNCLOSIM NOT MCLUDED,
POOLANMR SPA is
."flu MD COW, OF CONMUMMIq
PERWir MOM SUMM61bf
PLM CHECK RE 3 01 000-09-318 SM170
COWNTRUCTION FEZ 101-000-419-000 S27R.M
MECRANICAL AM- POOL 10-1-000.421-000 *24.00
BUICTRICAL PYW -- POOL 1014.000-420-000 $43.00
PLUMBINCI FEM .. POOL 161-000,419-000 S27M
U
AF 0
:3
OF LAO IN1A
I�EF_5 �9ell
rimfiNC1 UP'
Mrjl) Pi" (71F-Wf1W.
X,MS JPPYAPAYD FE70
Mrs DUE -NOW
BY 4 J 1 DATE FINALED
2910MAX)
SSU.70
$0.00
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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Equipment Location
Underground Electric
Underground Plbg. Test
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
Sewer Connection
Pool Cover
Encapsulation
/y
Gas Piping
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)