0302-017 (RPL)' LICENSED CONTRACTOR DECLARATION PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of ING PERMIT y°
�b51-13
f,—_—' •Chapter 9 (commencing with Section 7000) of Division 3 of the Business and ' DATE VALUATION ^'y LOT A TRACT
c4.W Professionals Code, and my License is in full force-and effect. , r �� -, �� ' $20,= w .
License # Lic. Class Exp. Date "� a'
/� �{�, ��yyyy�•1 �'I • JOB SITE APN
O W r i !� 1.t 6 i, D G is � J j�if: � • •ADDRESS 4� 27w '�17STA�i�w.�'�`'.�.��,i
6 Z r- Date i ? Signature of Contractor r �� / > OWNER CONTRACTOR / DESIGNER / EN •INEER
0.
� H .0 OWNER-BUILDER DECLARATION f TVA. 11+3 �C"/d MRS. T.�s'�`,����,,i.�H CANYON K/'�.�"� I POOLS
U ✓ 1'LA ; '('AAS?, lZ7d. RID
LU W I hereby affirm under penalty.of �ii�%'P VZTA f perjury that I am exempt from the Contractor's , f x
ADA STARMCIS CA 9,2262
C/) , License Law for the following reason:
Z ( ) . I, as owner of the property, or my employees with wages as their sole (760778-2700 M1.4 2951
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am, exclusively contracting with licensed 3'�)Ci7�.}'%)/Ql{y
contractors to construct the project (Sec. 7044, Business & Professionals
Code). - PC. OL SPA.. ALAPI�4'�l11•A UZ11rN s SHALL BE YN P�.AACE, AT PREPLAST
` () I am exempt under Section B&P.C. for this reason . WOPIzCTION• ?QUIPUMT YNCL. SMA NOT 1NCUIDED
N Date Signature of Owner
ON
• a Q . WORKER'S COMPENSATION DECLARATION
�. rv-Z I hereby affirm under penalty of perjury one of the following declarations:
n' HO O 1 have and will maintain a certificate of consent to self-insure for workers' i'OOLkd+�`O 10PA'00
Ls
K W' LL compensation, as provided for by Section 3700 of the Labor Code, for the .r
D -J'Q performance of the work for which this permit is issued.
Q C) (r) I have and will maintain workers' compensation insurance, as required by
] U. Q Section 3700 of the Labor Code, for the performance of the work for which this
L Z permit is issued. My workers' compensation insurance carrier &policy no. are:.
Carrier s ti , Ft)159?� Policy No. X61M. 9 ? Mir L.? COMERU —I!"ION
P, Muff. MM WIMMARY
J (This section need not be completed if the permit valuation is for $100.00 or less). 3. L" C14'FC K 3 F 101 -000-4e39-33, £� $1;4, g
() I certify that in the performance of the work for which this permit is issued, CON-STRUC:' I'M '14 1€23 -tics? �'!1 fyt i3�i $2(Y7'.l g
". I shall not employ any person in any manner so as'to become subject to the ,. ,e,
/ MECHANICALVEX -- I'83M 101 -000421�rt� SYA.tt4
workers' compensation laws of California, and agree that if,,l should become IS ry `
I Al / L Y eSLYC. R If;.AL M - .110OL 101-0004MOX) $45.00
3 subject to the w�tSrkers' compensation provisions of Sectio 3700 of�the-Labor
Code, I shallf?hwi comply with those.provisions/ '3�LE3'�t11rN01- ?,r' ., Pool. 101-000-419.000
Date: _-1 ,l {� Applicant X l s f11A 4
Warning: Failure.to secure Workers! Co pensation overag is unlawful and
shall subject an employer to criminal penalties and civil fine%"up to $100,000, in
addition to thercost 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'" i+
application.
1. Each person upon whose behalf this'application is made & each person atf <.(aQ• 0, OAq`f:ttrMOM AR(? 31�;�,Af03 W,d`�+Plt.3
whose request and for whose benefit work is performed under or pursuant to 4�
any permit issued as a result of this applicaton agrees to, & shall, indemnify LF08 PRIJ,-PATI) L2's1C?
& hold harmless the City of La Quinta, its officers, agents and employees. p
2. Any permit issued as a result of this application becomes null and void if O . 1r`i PKERMI %TUD I^1•C21�`
work iso not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. FEB 06 1003
I certify that I have read thislapplication and state that the above information is
• correct. I agree to comply with all City, and Sate laws relating to the building CITY OF LA QUINTA
construction, and hereby authorize representatives of this City to enter upon FIN
DEPT•
the above-mentioned properly for i,nspe ction purposes.
J( DATE, BY DATE FINALED INSPECTO
Signature (Owner/Agent)`.:;rn
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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
h
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
_
:'Jaste 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
iGas
Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
f
l
Underground Conduit
`
Rough Wiring
Low Voltage Wiring t
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)