0205-241 (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 -
�3F✓1 Z`�3 Cl53 ,MIT", C_ A fP%31/0
Date 21,S ✓ Signature of Contracto + r
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 issued1,
1- have and will maintain workers' compensation insurance, as required by
etion 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 �t'3,`�k,C(.)NpL0.4 Policy No: 04#�0D069i)5•� 1
(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 sho become
subject to the workers' compensation provisions of Section 3700 he Labor
Code, I shall forthwith comply with those roves ris:
Date: Pid� ApplicantF
+ '' iL. � t
Warning: Failure"to secure Workers ompensatio coverage is unlawful and
shall subject an employer to crimin I enalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as.provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth ,on his
application.
1. Each person upon whose behalf this application is made & each person at ¢
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify)
& holdharmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void 'f
work is not commenced within 180 days from date of issuance of Su
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information s
correct. I agree to comply with all City, and State laws relating to the buildi
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property. ff5p. inspection purposes
,Signature (Owner/Agent)
BUILDING PERMIT PE�`y"0`},
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2C
'DATE �' VALUATION LOT TRACT
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5,1? p/ J -s•JOB
SITE
ADDRESS *�r= a.3�o.-s� J�,
APN �. .
OWNER
CONTRACTOR /DESIGNER /EN 1NEER
T.D. DE9F0C DWq0P-hr
ypS,A)P MANtCO
PAUY'lttJAP00,3 & SPAS
"P.O. BOX 1116
'74 725 JMU-TALIVE, 3WHEM
L_ (I)D3N't`A CA '922S3
P.!a,.L;+9.'GiUSERIT (,- 922160
(760)340-9000 CK10 OW 5<5
USE OF PERMIT
PCYC7'�.AN"9%OR VA .
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.
F1 P+AtglAT if1,1P VfZR -43 .I.0 ION. PuiaEQUIP M.pi
iC[a 5!1 tf :g$Cl'1 INCLUDED
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PLAN CREC19ft'r, 01 -i000-4.39-3 18 S-140,40
+'i xin'l c '.1014 nuc 101 _t200 -4.18.00C4' z�'.i3tt
MECHANICAL Flet_POOL 101-000421,�0 0
9LEC1RJC:ALPrZ»b; POOL .101-000-420-000
�'l,IC1Ah1?JAis1 ��i� ..:1aCl�ti3 :`' 7�;� y(9f1i3d�1 �MC9irJ �YJ.D�
GOB- OTAl, CONwffI'M Tn-1014.40t3- P' (.w"4K.
$02.40
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MAY
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CITVOF JA QUON
IN
RIVANCEI)rA
RECEIPT
DATE
DATE FINALED
INSPEC
l
:p
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
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
�Q2
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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
Final
Q-- — Z
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: