0102-180 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter g (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 ate
X 51 fi:4 R C-27
Dat" a Signature of Contractor,"(
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.
Y' I have and will maintain workers' compensation insurance, as required by
S 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.
MID-CUTURY ANDS -69-37
(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 hot 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 Segtion 3700 of the Labor
Code'
Applicant
I shall forthwith comply with those. previsions-o',i'
ate:•— f
_g
Warning: Failure to secure Workers' Compensation ..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, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
.. Y! i
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions setforth on his
application. #
1. Each person upon whose behalf this application is made & each person 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.'
2. Any permit issued as a result of this application becomes null and void if
work isnot 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 inspection purposes.
Si' nature
(Owner/Agent) ✓ G r .r ��4 ` Date
BUILDING PERMIT PERMIT#
DATE N VALUATION LOT (b�^�.. f' TRACT
'
JOB SITE Y r� f`
APN
ADDRESS
9) 1-M KIN 0:fi`F11G M-4.:1. HE
-
OWNER
CONTRACTOR / DESIGNER / EN INEER
DME RT `MENS CONSTRA 1VT10N
74-92.J 11C>MY3A�3►.�1? ° 1 6`'ti1IF32^220
41555 TUCCAl.MTE
PAW MRT CA 92200
IMN A]f UNES Cha 692201
C/00)360-4+400 3OA6
USE OF PERMIT
00L.A111MOR SPA,
E*GDY.BVltALF1Rit+III&'R.S2.RJERSS.KpiYrr;.USIN' lalACE ANPPJDP1.Au"i'FR
IN VZOTi3ON, POOL L114CWBBI€ E EQUI1'1! MIT IS NOT 1.NCY tt0RD,
F'OOLA3+lWOR SPAt 41rJ!�.itt1 I's
ENDMATM +CORW CO:i�;':a'l:1M7110V
124MA10
PERM VER HUMMMY
PLAFI CHRCK FRR 101A700--439-338 8`4it73
C014STRUC a iCi"H MR 101-0001418-000 $135.00
M, MCI`! KALIF-9-»PQ0L 101.000421-000 $14,00
FA.�., TRIC.a13L PEE •,1 POOL . 101-000-4,20-000 $45.09
PLUMMO E .- Pool, 101.000.419-.000 427.00
UEM PR: -,PAW 1VVZ
MIDI()
FED 27 2001
e �u�
RECEIPT
DATE
BY { j'
�'I/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
�41et Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap..
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Set Backs
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts _
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Underground Pibg. Test
POOLS. -SPAS
Steel
Electric Bond
PLUMBING APPROVALS
Main Drain
Approval to Cover
Electric Final
Equipment Location
Waste Lines
Underaround Electric
Underground Pibg. Test
Final I I
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 Connection
Encapsulation
_
Gas Piping
Gas Test
Appliances
"
Final
COMMENTS:
„
Final
Utility Notice (Gas)
ELECTRICAL. APPROVALS
Temp. Power Pole
Underground Conduit k"
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)