0101-002 (RPL)' LIN - , LICENSED CONTRACTOR DECLARATION
.I hereby affiim 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
V D 2324 11 XRT:
Date of 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.
( ) .I have and will maintain workers' compensation insurance, as required by
Section 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.
.i3u p"R. PT
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the'performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subjec to the workers' compensation,.prov sions of Section 3700 of the Labor
Code, shal forthwith comply with thp�$ r yvls ons.
Date: 91 Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. 41.2 . .�:
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property or. -,/.I tion purposes.
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Signature (Owner/Agent) f/jr'tf e]C,� Dated
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01f33. -W1 TRACT
✓✓
% Wim' 1 A.Cf ini t 4 R?'$ X45
JOB SITE
APN '
ADDRESS
5.1-2811 AIA(MIMI& 01.81MO ION
OWNER
CONTRACTOR/DESIGNER/EN INEER
RICES.19 SC,"t':J`.E`T
P.M.' k'1101H0?,. M
b?I D(YX z 0612
7 564 A COUNTRY CLUB D12dVE, ;3*0ft. 113
IIAIM CA. 92255
PAUA.7.��i'�",v�ff CA _`4291 '
C760),VIS-3495 C1191101 2953
USE OFPERMIT
P^CynAWOR SPA
st'00L. At S RA ONLY- AA tU".MSMA!t,1LF4'. XR.S SHALL SLS IN PLACE AT f'+kt:
PLASTER rNIUMMOK[N. OIL J?.QC1tiPMeXT lNtpW,". URA 10 NOT S.AECT,UDY'D
IN THIS PERMIT
POOL, AN SPA 14,000, DO 1S
E4'�°1�;tiJ�." ti°��'rDi �,ON9,1`RUC�1.4'�NT
� t 9st?dD
ARY
PFR MI r FET. SUMMARY
PLAN CHYXX RE 101-000--439-318 WAS
1=14S Tre XTION FELF 101-000-S 1 f;-000 $133.61)
T+fiE1v4IMICAL, rMX -- POOL 101-000-421-000 $24,00
E'I.X,^`YR',7CA, i? 'A�� .•• F�7t.iC. 1 C1-liC3C?- 2Cd-C£} ? X34 �.rJ91
PLUMBF114019?E -- Pool, 101 -OW -419-000 $27.00
1R
,
MR -TOTAL 001SdU(T110Nfi M.) ,tale CHECK
$348.45
LRBS I*WPAf}AI d;MI
$0.00
`i'MAI, FEMUT l YES DUE NOW
9346.4
RECEIPT
DAT f/
BY
DATE FINALED
INSPECTOR
ft
�� w -
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel-
Roof
teelRoof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Paity Wall Firewall
Extirior Lath
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
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
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
Fans & Controls
Condensate Lines
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underaround Electric
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Final
COMMENTS:
N
POOLS -