0107-245 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6 2S C5,3 IKTC
eel
Date �' Q''a Signature of Contractor�x�*a f;�p.;✓�
� F y'
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 license('
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.
ad 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 Policy No. '
STATE CCAAFFYISATI 0161"
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with t ose prbvisionsi
Date"'""-=f✓Applicant_;u,•—
Warning: Failure to secure Workers' Compensation coverage is uniawili+'r
shall subject an employer to criminal penalties and civil fines up to $100,06
addition to the cost of compensation, damages as provided for in Section 7�
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and S, Ity
for a permit subject to the conditions and restrictions set forth oi his
application.
1. Each person upon whose behalf this application is made & each per on at
whose request and for whose benefit work is performed under or pursu
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 applicat;on 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 propertytfo inspection purposes -may
Signature (Owner/Agent) fi r Date {:,.~. e,^ri
�.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT p3Y'f.° TRACT
WAIL 24
JOB SITE APN
ADDRESS
91-240
OWNER CONTRACTOR/DESIGNER/EN (NEER
TOLL BR(YrRIMS WC
1,4-9231100 .LY LANE 1"'N' P?:)1'IE2420
.1'ALM:DF.W_ii3' Ch 92260
USE OF PERMIT
P0('iL , D/0R XPA
CALIFORXth 1-1001.0 & VAS (I -OP MAN
PAI 14 DEVER:c CA 92260
C160Z340-59-0 0 CBVI 351,
l?!)DY, & SP�k - P1.t.31MIT DOZZ NOT 1Nf;1„CfD.E. YsLOC K WA,t:,'L, ALP.R&IIS
9, W.; , iron` .i` 3 4 FAs.3..YD W)It. PRE- PLASTER WSPEC TION,
POOLANDIORSPA
2K00.00 L3
COST OF i.•ONIR'�t; Crion
(� ��[�ryy��ry�,.�•Xgr=411D
j], FEN
aX� Mff FEN i7�r..1i?•.d:1J�A R.Y
11F, •- POOL
101.000.421.004
S214,910I
Lei.t+:.CT9.W-AL WE m, >?salOL
101¢060-4204100
W.00
PLAN CtKI:C sir'.
iC+1-t1GtJ-439-39 ?
515;.3)
CCxY'2S'i.1. C T ION Rr"
101 -000 -4 8.000
52A3,00
i
JUL 26 2001D
CITY OF LA QUINTA
_FINANCE DEPT Nly1400T 1X1101qA;~FDP1 —,kt] +C'MC
M5323 PRFVAM 1W.3
TOTAL YkRAW r, KES DICE HOW
RECEIPT DATE I�`Y7 ; DATE FINALED I INSPECTOR
$496.95
$010
14A9*
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
Steel
Electric Bond
POOLS - SPAS
f�IW
-
BLOCKWALL APPROVALS
Set Backs
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
/ l/
Final
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 /"�UV__
_
Gas Piping
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)