0103-217 (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
s�G /R�#s/� LL2ic.. Class Exp. Date
Date ", ,n - Signature of Contractor
OWNER -BUILDER DECLARATION
1 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 projer> (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.
Se( :) I have and will maintain workers' compensation insurance, as required by
ction 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 WMD 04000168-00
(ThWsectioh need not be completed if the permit valuation is for $100.00 or less).
O I'ceAify 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 tho a rovi ons.
P Date: Applicant
�.� ,�.r ..
Warning: Failure to secure'Workers' Compensati n coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damagesas 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 Sa E
at�
for a permit subject to the. conditions land restrictions set forth on i
application.
1. Each person upon whose behalf this application is made & each perso
whose request and for whose benefit work is performed under or pursue
any permit issued as a result of this'applicaton agrees to, & shall, indem ify
& hold harmless the City of La Quinta, its officers, agents and employ S.
2. Any permit issued as a result of this application becomes null and vo if
work is not commenced within 180 days from date of issuance of s ch
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 inspectionpurp s��.
k ,79
sig ature (Owner/Agent) 111A� F t Date
BUILDING PERMIT PERMIT#
.DATE ^ _1 ALUATION LOT �� -� `j TRACT
$259WAXII 14
JOB SITE
Kin
APN
ADDRESS ��yyA &kr66uf�C
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
0. EA ox 17 16'
74-725 XOMM.M40A
LA Q1JW TAS. CA 9225
Ptum men }! CA 9 260
(7 m),.mo-g000 Mf 538115
USE OF PERMIT
0111, AMIXOR VA
P001.,f5PA1100Q1F4I:EWIT, ALA V:Ei..€GR.FF.IERS Sf%l,LIA, BUY rN PILACE.61,T
PTM,PWTY.R INSPEC.`'r .OrK POOL aRQT.y.IPMEPTT MNCV'tYWILF,19 NOT
FN[o°I.,1315FI)1`?1.TP'31aiI'isCtku'1T,1,K8QA-1iS1,.ZEA-53-.f9.9a„M%'.PIT A SI 49 GAL
POOL 4D/OR M 23j900,00 LS
Py-�R264 S '
�ry'+Xy'/,61101.1
�� PEP. 101-000439-:318 MOM
!q*WSTKOC` ION r9t 101-000.418.000 $25950
WaC HANICAL t VA?. -„ POOL 101-000.421.0DO 124.00
&LACTR'IC.a 1, PtPT, as POOL 101-000-420-000 $43.00
101s000-4 -000 �
Q U.
MAR 2 9 1=
, r :N , +'RUMOR A�:�T ►tP�.1,i ;`t��t�p�Y��d�'y`.�t��y
. • J,rhrxi'aZ3 �d�' "���'887J �`.Giv.:�.y
$0, VN
CITY OF LA OUINTA
FINANCE DEPT`MIXIR'.�i!•�!MEIf' IM-411?nfi'O
�!$ .11153
RECEIPT
DATE
BY:�
,r
DATE FINALED
INSPECTOR
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
Set Backs
steel
Electric Bond
p _
Footings
Main Drain
Bond Beam -
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
_
--
PLUMBING APPROVALS
Gas Test
Electric Final
aste Lines
Heater Final
• "ater Piping
Plumbing Final
P iumbing Top Out
Equipment Enclosure
--Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
_
_
—'
Gas Test
Appliances
Final
COMMENTS:
Aly
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) ,