0107-246 (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
6,561.28 G5,.3 7-Ff..c° Qf.1 �xciJ�al�+
a_
Date ~� �a? Signature of Contractor-A'.12'X • '* P
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&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.
�r I„ have and will maintain workers' compensation insurance, as required by
S�t9tlon 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:
Carriers 9a �1yT si 6 c Policy No. �lCla2��q Co
i7'�.��Fr �� �.i✓.�fi�,5-.L.,.F`C�I9 !'.� 4 �;iWAJ¢tl N�3
(This section need not be completed if the permit valuation is for $100.00 or less).
—(-)-1-certify-that-in-the-performance-of-the-work-for which -this permifis 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 those provisions .
Date:" Applicant f
Warning: Failure to secure Workers' Compensation coverage is unlawful ah1
shall subject an emplover to criminal penalties and civil fines Ian to $100,OOn j i�
addition to the cost of compensation, damages as provided for in Section 3 �f,
of the Labor Code, interest and attorney's fees.
'IMPORTANT Application is hereby made to the Director of Building and Saf
for a permit subject to the conditions .and restrictions set forth on is
application. t.-
1. Each person upon whose behalf this application is made & each perso at
whose request and for whose benefit work is performed under or pursuan 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 author�e representatives of this -.City to 'enter upon
the above-mentioned property for Inspection purposes.
Signature (Owner/Agent) /'`�+'� /.'. Dat "�
BUILDING PERMIT PERMIT#
-
DATE VALUATION LOT 01'7-'24A TRACT
t2• O.00 = a c�
JOB SITE APN
ADDRESS
OWNER
CONTRACTOR /DESIGNER / EN (NEER
' 5U, D�t.<1IT � INTC
L�.��..1�'C3i`�I�d A �"C.�OLS & WAS MP MAN C01
74.923 HOVEJY 1ANI �• T�A'�'�" Sir1 2.220
74 25 J0111. T; RIR '' VE A
P.A�Uel D1a:�a't;L��'.'!" CA 92260
PAT�?A, D,f~ ` " T CA 92260
('iE ).14flr•9�, 00 L: 4• 335
USE OF PERMIT
POOL cg: SPA. • PVcMIT .DOES Rs.)`.f' )NC LUDIC ;3 LOCK VALL ALARMS
VRAM, BF, IN`r�`,f°f�U-91) FOR PRS -PIASTER 1'P SPri.., 1110m.
POOL.��il;> R 0PA. 3�4ttl4 00 L9
Xnavul9p CONT 0.21-P
_ _
-
E,i���.ggy���ppTyyyyi,'1ti7Q;,`,Pig.�,yaF12- 101-0�piyl0-4 09-Ui03y0 $43.00
f
p-��yP�E�gC�i.
19-000
PPal4d$tiY3311,40 3'n•'sY'✓ `_ P(X,)L 101-000419-000
PLAN Ciifl-C C F6; I: � � fJ-OI�F�-�i•:i �-a Y �S $'i 63. �0
ION113TF2U(' 1' all FES 101-000-41V-000 �oK�riiO
I )
j !
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r
ti
J U L 2 6 2001
•.
CITY OF LA OUI_N�WT�1
FINANCE DE k "'Cid , t)i 171�$:Y:fC'S, ON 'AMP ,1.,fAi� I FS�,X5
$511.80
F_'iJAF2L FkaWrIf YYXS L"l."Ri YRO'C'!
1..8o
RECEIPT
DATE
,BY r
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
y�
_
Set Backs
Electric Bond
Footings .
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
_
oil
PLUMBING APPROVALS
Gas Test
O
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
I Encapsulation
tt
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)