0010-220 (RPL)N]
I
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
—P6.rofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
CV56128 t 521 1W34t'2i
Dater 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 (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).
O 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 andiwill 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. s'"
C: ) I have and will, maintain workers' compensation insurance','.as, required by
Section 3700 of the Labor Code, for the performance of the work fo'r which this
permit is- issued. My workers' compensation insurance carrigf & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or les's).
( ), 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 provisions of Section 3700 of the Laborl
Code; shall forthwith comply with those provisions..
Date: r Applicant
Ir
Warning: Failure to secure Workers' Compensation coverage is unlawful and-
shall
nd -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 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;w''A
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.
Signature (Owner/Agent) ` �r Dater,' '" VJ
BUILDING PERMIT PERMITN
DATE ! EVALUATION LOT TRACT
JOB SITE I
APN
ADDRESS
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OWNER))�/(rY
CONTRACTOR/ E�R)r/EN I(Ny�EER[y
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gy �y
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-15345 601 alb° ���'M`t. UAIR 4.200
74-725 J0.01DIUV'.� ##A
±yPORF.11M.-IABDWO CA +12408
VA7;JA���''€ IRli' ; CA 927,60
"
(f(%i➢)mog q(yl)o 355 ;
USE OF PERMIT
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tips pad J1p P�qc• 7tf f nary9�I C q eu Y
C'�.,�-��.� dN: rJSix"�l. 4/l'v U.a 1J^,�.laJ<t,Tat%. �iY/fJ �dFl4 �.�1; 1•N aYBi.!'1.JA, If4K. /:9�`7 f�b�..7f,.0 AT PRE -
1"1QAFA`CP,_� YNSP C TIONYO.01. FNQUlPMVXT T�CJ?a3RE IS NOT fN€;.UME R
IN THIS PERMIT
POOL ANDIOR SPA LB
F. -INKM6,,C09r OF CONSTRUC ON
-PER, ta3 iriv, stI��`mZ°�
P3,AN (,114EC 9 PLC '- 101.000.43? -318 .1111111
CONSTROC.TI lid •%`EE _ 1011-000.41$-000 $1°71.60
MFICHMICAL YEZ _1 POOL 10 1 �0004 21 -000 SAM
1�gpp��ktjv���:��'d',?Y11��C77.•//,gM.1B.,� �pqr�c e •n 41pZ�f, ol1, ,0
$49A�0y
{) p01,o-0So1pP.�?-r�139�e-tE�1t/10
91;1:13<' 0TAL C1'C9NS7RM-1',` 10H AM) PLAN CHECK
N TMAL VON, NOW
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RECEIPT D
BY j`' :f
DATE FINALED
INSPECTOR
:A
INSPECTION RECORD
9 OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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
Final
Underground Plbg. Test
Gas Piping
'zli4-
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K. for Finish Plaster
Sewer, Lateral
Pool Cover
/
Sewer Connection
Encapsulation
_
Gas Piping
r,v}
121
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)