0204-100 (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
Professional's Code, and my License is in full force and effect.
License # Lic. Class ' Exp. Date
`6561218 � C,-JVac C-8
Date `—� Signature of Contractor—
OWNER-BUILDER
ontractor 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&RC. 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.
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 3TATRC-a10?l�l�ki1~tAT1 Policy No. ir9600N06.8-91
(This section. need not be completed if the permit valuation is for $100.00 or less).
—H -1 -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 compensationfprovisions of Section 31700 of the Labor
Code, I shall forthwith comply,,with those provisions. 1
Date: �. `` -44 ;Applicant j
Warning: Failure to secure'•Workers' Compensation coverage is unlawful and
shall subject an employer to criminal Denalties and civil fines Lip to $100 nnn, 'n Y
addition to the cost of compensation, damages as provided for in Section 370
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. I
1. Each person upon whose behalf this application is made & each person-at--
whose
erson-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.
i Any permit issued as a result of this application becomes nulFAnd void if
work is not commenced within i80.days from date of issuance of such;
permit, or cessation of work for 180 days, will subject permit to cancellation,'
s
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.,!' ,+ t
Signature (Owner/Agent) '.?!/s✓ri/�''�� Date
BUILDING PERMIT PERMIT#
DATE VALUATION v4p"160 LOT TRACT
JOB SI+ E f
ADDRESS viY—1.rITT OVTON IMAITT
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
T012. I i.'`1'I3✓s %S `d(".
(IMM, rte.PO01A & VAS (JVP NfM CC,
:13A1: J1 DEMIIT A 9.2260
PALM 1)E �1W'WT (,•,',A 92260
(760 340-91000 CpAlf 00355
USE OF PERMIT
POOL AiXLV0Rf1,PA
POOL AND SPA ONLY. .85Q A143J 22141.1991. 4 LY OF 3' OL(=
WATI CgTY ST.K14DART), ALAIR vIS3DAAI RA14I S SHALL DE IN PLA.e,L 1'1U
TO PIRV31AJ' ER INSJOW" IOV. POOL RQUIPMM [01C) OSURIP,War
POOL AVD,�R PA. 24,000.011 I43
111`: BALL
{' N
-
6._25 -
CO3YS 3.tt.UCTIOlTd VLZI 100.000-418-000 $225.0
CONSTRUCTION
MMIANI :AL FEE -- PGOL 101-1000.421.000 t324,4
PI&IME111+101MV -- P0011
. N �
{r 1:' 2902 '�
aa
M 1Tii •
f�77�' yy
�
9118-TVIAL CMWAR'f;lx;?i"t04'AVO PLAN CSEC,M
JX -30 PRTt-'fiZD VFX4
RECEIPT
DATEBY
y
DAT IWke
INSOR
G /
n)
'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
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 ConnectionEncapsulation
_
Gas Piping
Gas Test
Appliances
Final
� 1
COMMENTS:
Final
Utility Notice (Gas)
rug
dN !/
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)