0210-302 (RPL)LICENSED CONTRACTOR DECLARATION;'
U) I hereby affirm under penalty of perjury that I am licensed. ro,Aiions of
Chapter 9 (commencing with Section 7000) of Division 3 of 1he,,',Buki9ess and
C14 U) Professionals Code, and my License is in full force and effect.'
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ZS Z) c) License # Lic. Class Exp. Date
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• Signature of Contractor
OZ t� at�,�,,' 4�4 I}Z
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I.- C:� OWNER -BUILDER DECLARATION
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HLLj rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a�
U) License Law for the following reason:
Z 1, 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).
1, 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
LO
C\J Date Signature of Owner
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< WORKER'S COMPENSATION DECLARATION
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0 � fr I hereby. affirm under penalty of perjury one of the following declarations:
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, �-_ 0 1 have and will maintain a certificate of consent to self -insure for workers'
X LLl compensation, as provided for by Section 3700 of the Labor Code, for 'the
O0..J _-J < performance of the work for which this permit is issued.
<. L) I have and will maintain workers' compensation insurance, as required by
O < Section 3700 of the Labor Code, for the performance of the work for which this
0. u). permit is issued. My workers' compensation insurance carrier & policy no. are:
.t. Z Carrier RATSCOMPENTSATI Policy No. N0900060-02
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< (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 thogeiprovisions.
,,bate: 1/'Wn Applicant—/ Z
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.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
applioation.,
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 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.!.
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construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property,,f6r inspection purposes.
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6§gnature (Owner/Agent) - (
V 6:,1' X;" Date
PERMIT#
UI "DING PERMIT
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DATEX" '"'TALUATION LOT TRACT il I I $191c"M
_A4 I a,5h!5AJ I)ALI flg r_,qs:4
JOB SITE -!' '7 APN
ADDRESS 951-620,
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OWNER 7Q- & 1CONTRACTOR IDESIGNER FNdINEER
TDJT)Z.%.'JZ1'MV &
BOY. 1716 86- 100 AVZIME 64
tA Q10INLk CA 92253 C'0A(°'rr=..A CA 92236
(7150)S98-9222 CBVI 0035-5
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USE OF PERMIT
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P00L,A1,,T,P/C�',R VA
P00US-11A, 20 I.Y. 'S' 0ARMN WA?J TY STAINDARX).
A1ARMA0,JR#NRR1f8 SHALL 'BE V.'a"'19R. AT PRE -PLASTER MMY.-ITION.
5 FT, WALL 20.00 LF
'POOL A14 DIO R 911M
LUKIMAXED COW Or' C40NE-11RUC110,11
P 111m, su
PUIN CHECK FEE 101,40U-4-39-318 P22.70
CDNSTRUCTK�N P?,E
YMCWNICAL FEE- POOL 101-000-421x00`0 $24.00
XLECTRIC.-M, PRE - POOL 1,014-000-420-000 $415-00
pumuoNo For -- pwj, 1010-000-419-000 S127100
SU-S-710Tfial 10014100RUC�1100 AND PLAN CWHEXINC
LESS FR. -PATD TWS
U122:70
$0,00
.CMAL 1101MY F Sri 9 3111TE 170W $412-70
RECEIPT DATEBY DATE-BNALEP INSPECTO
INSPECTION RECORD
lOPERATION
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 PIbg. Test
Final
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)
�j ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough -Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
ExteriorReceptacles
G.F.I..,, -
Smoke Detectors
Temp. Use of Power
Final 't
Utility Notice (Perm)
I I