0209-010 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that l 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 .tom
IZ x-:53 RICO I,°:8
Date'el;kf- ( Signature of Contractor l " a
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.
K—) I have and will maintain workers' compensation insurance, as required by
Section 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 .,,81,,A' (t,;lei-pM43i,1rJ Policy No. 4 4�f►17151tjd-01
(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`p"rovisions of Section 3700 of the Labor
Code, I sh II forthwith comply with those provisions%
Date. Applicant. , IlLw�4r w
Warning: Failure to secure Workers' Compensatlio 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 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 per t f
whose request and for whose benefit work is performed under or purs
any permit issued as a result of this applicaton agrees to, & shall, ind
& hold harmless the City of La Quinta, its officers, agents and empl s
2. Any permit issued as a result of this application becomes null and i
work is not commenced within 180 days from date of issuance of, 8 u
permit, or cessation of work for 180 days will subject permit to cancel) tion.
I certify that I have read this application and state that the above informatl
correct. I agree to comply with all City, and Staterlaws relating to the building
construction, and hereby authorize representativbs•of this City to enter upon >
the above-mentioned property for inspection/purposes:
Signature (Owner/Agent) �= DateyL:
• F.
BUILDING PERMIT PERM T#
DATE '+f°, J "� VALUATION LOT TRACT
JOB SITE
ADDRESS a ,LA
APN
«
OWNER— 1 f
CONTRACTOR /DESIGNER /EN61NEER
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yAS (Ki11 MANCO,
0,AVAR✓4A POS¢ SMAS
PO B033C].7..6
36- I ?OAMME y4
aAQ NYA CA, '9A253
ryA. 922
N.krH L)—k 36
USE OF PERMIT
POOL MLIVOR WA
POO1JdI' A,fiE3Q ALAPIMS'F3.ARRIERS SHALLBE ITS PI.frlCY, PRIOR TO
P''001. ANWOR SPA Ibd3W.tifj .la
ESIMMTED COSY OF Q ;i'a NS'"dN17MON
21,-A)D £iii
�+�fl"�rz33ss'II�' 4aE7�3�
PLAIN CHMIX "IE WOOS
COtaSTRUC11014 Pit 101 -000 -418 -OW $225.00
Yo9EcamalG'&LF�km- pool, 101mOOVT421.000 $24,00
&'1.1'? :' XIfWAL PAVE — POOL 101 -OW -4-2.0.000 $45.00
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EP 9 2002 IS
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17Y®FLAQUINTA
FINANCEDE-
RECEIPTDAT7r
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BYE^
DATE FINALE
INSPE Fl
a�,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
_oz
Set Backs
Electric Bond
-/ -oz
Footings
Main Drain
9 —j 2 —vZ
Bond Beam
Approval to Cover
—
Equipment Location
Underground Electric
.—�L
Underground Plbg. Test
-Final I I
Gas Piping
PLUMBING APPROVALS
I
Gas Test
Electric Final
— �p•�
caste 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
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: