0005-341 (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 f "'rce and effect.
License # Lic. Class Exp. Date
672850 C53 Inc. " r 06/3()!2(
:Dates �^� ¢-"k�'`°' Signatu•re•of�Coritractor'/ �•- ,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that l 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 & Professiorials
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.
(L
)—l-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 FREMONT EMPLOYE Policy No. WCN30 602 2
(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,shal; forthwith comply With those provisions.
Date: `' :L Applicant . ,,. �. .'�_--t`:..• �` ,.
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.
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 for inspection purposes.
Signature: (Owher/Agdnt) Date
BUILDING PERMIT PERMITfi
i�
DATE VALUATION LOT V 0005-`341- TRACT
JOB SITE
APN
ADDRESS --05 AAT+:.MA OB.i EG4()1q
..
'OWNER
CONTRACTOR/DESIGNER/ENGINEER
LA QUDJTA PARIWMS
GAYI TJ30 FOOL PLTJhM N,3, INC
PO BOY 134
667 FUGMC RLQ.
LA QUINTA bA )92253
PALM SPft NGS CA 922%b
}
(760)327-7592 (M..W 816
USE OF PERMIT I
POOL ANIVOR. SFA.
POOL:.'A ONLY-ALAP-,M-APR1FRS SHALL 8E rN PLACE AT PRE
PLAVER INSPECT A ION /1%
POOL ANDJOR SPA 12,000, 00 LS
ES'dIMA13D COST OF COiVSTRUMON
12,00MOD
PERMIT FEE gUh ViVAIY
PIAN CHECK FFX3 101.000439-318 $37.75
CONSTRUCTION rEE 101-0004.1€5-000 $131. 00
RLEC PRICAAL FE •- POOL 101-000-120.000 $45.00
PLUMBING }SLE — FOOL 101-000419-000 $27.00
�i
SUB -I AL C';ON9MUCMON AND PIAN CIECK
$294.75
LESS PR-PJVD:Esq
:fi0•C)i)
TOTAL :P hIRMT FATES DUE NOW
16
RECEIPT
DATE
B / 'z
DATE FINALED
INSPECTOR
Z
W
INSPECTION RECORD
OPERATION _
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs i
Underground Ducts
Forms & Footings I
Ducts
Slab Grade !
Return Air
Steel }
Combustion Air
Roof Deck i
Exhaust Fans
O.K. to Wrap j
F.A.U.
Framing
Compressor
Insulation I
Vents
Fireplace P.L. 1
Grills
Fireplace T.O. I
'Fans 8 Controls
Party Wall Insulation i
Condensate Lines
Party Wall Firewall
Exterior Lath 3
Drywall - Int. Lath
I
!
Final
Final I
BLOCKWALL APPROVALS =
POOLS - SPAS
steel
Set Backs I
Electric Bond
Footings t
Main Drain
Bond Beam I
Approval to Cover
1
Equipment Location
Underground Electric
I
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines }
Heater Final
-Water Piping I
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans !
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 1
Encapsulation
►Gas Piping i
Gas Test i
Appliances I
Final
I
I
I -
Final
Utility Notice (Gas) 1
,
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring i
Low Vottage Wiring I
Fixtures
Main Service [
Sub Panels I
Exterior Receptacles
G.F.I. I
Smoke Detectors I
Temp. Use of Power I
I
Final
Utility Notice (Perm).!
COMMENTS: