0102-125 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm,urider 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. I.
License # Lic. Class Exp. Date y.. .
Date 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:
( ) 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 (Ser.. 7044. Business & Professionals Code).
%( ) I, as owner of the property, am exclusively contracting with licensed
ao?itractors to construct the project (Sec. 7044, 'Business & Professionals
am exempt under Section B&P.C. for thi reas n
/Date !2 .1 - Signature of Owner
k
^� WORKER'S COMPENSATION DdARATION
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.
( ) I ha6e 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 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 s. all not employ any person in any manner so as to become subject f6. the
workers' compensation laws of California, and agree that if I should becme
subject to the workers' compensation provisions of Section 3700 of the.Labor
Code, I shall forth ith comply with those provlslo•l
Date: f 'k .. '1 .Applicant r r ^~ w
.Warning: Failure to secure WorkerssCompensation coverage is unlawful and
shall subject an employer to criminal penalties, and civil fines up to $100,000in
addition to the cost of compensation, damages as provided for in Section 346EE
of the Labor Code, interest and attorney's fees. �p
IMPORTANTtApplication is hereby made to the Director of Building afr�'Sbfe'ty
for a permit subject to the conditions and restrictions set forth on his
application. iY N
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or, pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is .
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property,for inspection purposes.
P
Signature (Owner/Agent) _. Date `^ t••'s*'1�
- BUILDING PERMIT PERMTk
DATE VALUATION. . LOT {$•Sf `a7 TRACT
rN+
JOB SITE
APN
ADDRESS
784WASMD CeLT9
•• ••.
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
Fr 114I$'t.3�'PiE
t7�1 MU1Z:�r��1�'€Z
IA QUDUA CA 92.253
z.
USE OF PERMIT
PC.)C,L A;°kDOk SPA
P00i, &� SPA t'3Nt..Y.AL..ARMSfit3l+iC..h'_TBV1S 53Mf_L HH'' .?N PL .~aMAl P RIP,
PILA',T' AINSPEC,T100,P001,oYQUtpmpwr meLOSottf;' fis'3iOT' 'A3mI.rarto
Ta x THIS 8'.EEMI T",
IZJQ JL AN r` IOR. eiPA
'9171TWAIM) COST 0F CONS-113fic).1011
PIAN C:fl9Ca4 I E71 �C1iGC J ^4g3C?�" ? $122,85
WNS'�,�.���.'�'Fr.. N VC1,2YCf1 <i��1f& :1 c9'^� -�i $190.06
APXCHANI: ALS FEE -- POOL' 101-000421.00K) $24,00
9L C6'3'r'GAP. �f3- — PMA �1�}).-000-42,:?•000 �q.00
PL-AMl~cR10ItEE:._ POOL:1411.0100.41"9.001) $27.0
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-SUB-TOTAL COMRS—ITC170RAND PLAN CHOXICK
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3
RECEIPT
DATE
BY �,
DATE FINALED
INSPECTOR
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
V
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
Pool Cover
Sewer Connection
Encapsulation
_
Gas Piping�.Efl��
Gas Test
Appliances
Final
-
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
F'bctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)