0107-281 (RPL)LICENSED CONTRACTOR DECLARATION
N 1 hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
C M License # Lic. Class Exp. Date
1�_Q LO
C53 Mc
cZq to e""" q,. �! Signature of Contractor'
0_ f-
t— OWNER -BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z( ) 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).
M () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
OC\J
a Z WORKER'S COMPENSATION DECLARATION
o cc I hereby affirm under penalty of perjury one of the following declarations:
Lo FQ— O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Qperformance of the work for which this permit is issued.
m Q () L,( �) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
� Z Carrier Policy No.
ob O 111 -TATS S 1.10A•P i�t�ATI C�6+�St§1fl T,pi."4
g (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
3 Cpde, I shall forthwith comply with those prvlsions. y�
`Date: - Applicant ! • , F
Warning: Failure to secure Workers' Compensation coverage is unlawful,
shall subject an employer to criminal penalties and civil fines up to $100,00
addition to the cost of compensation, damages as provided for in Section 3
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Sal ty
for a permit subject to the conditions and restrictions set forth onis
application.
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
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Ouinta; 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 inspetion purpose
m.
<Slgnature (Owner/Agent) ^'" j Date_;
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
07M)PIK 04,0000)
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
Ms. R8INC
V,.A15?0PKLkPOOLS & OM (K)P.,veN COi
7 4.923 tIOV'OUfW.1. _R ?` MIT11,2420
d 47 2.3 JOM DRIVE,,RME SPA
PA1, : LtLi,'.MR1. ' Chi. 922600
PAtIM, MWIa ('4A 02260
CM)34-0-9000 (M.4 355
USE OF PERMIT
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PLAN Cfl; FRIT 101,.000 439.318 $957,95
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101-000-420-000
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- 01 -000-4 9-00 7 +861100
JUL 2 6 2001
,
CITY OF LA OUINTA -
FINANCE DEPT
M+ _ H ; C�3 rECK
$496.91
1XIM PIM RAMM0
$0,00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
JA
.!
"KW
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
v
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
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)
I