0109-105 (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 # L' ` ' Lic. Class f a Exp. Date
7782,40 0.3/71M
GpateP Signature of Contractor
OWNER -BUILDER DEC ARATION
I hereby affirm under penalty of perjury that I m 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 isnot intended -or,off ered for
sale (Sec. 7044, Business & Prof essionals•Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). i
O 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.
EXYMPT
(This section need not be completed if the permit valuation is for $100.00 or less).
�(r) 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 those�provlsions.
D e: �' • �� Applicant e.
7_7
Warning: Failure to secure Worker Compensation coverage is unlawful and
shall subject an employer to crimin penalties and civil fines up to $100,000, in
addition to the cost of compensati , 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 personat
whose request and for whose berfefit 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
theabove-mentioned property for inspection purposes.
Signature (Owner/Agent) ^' Date
BUILDING PERMIT PERMIT #.
t.
_
DATE VALUATION LOT4f' TRACT
A 17 TV"r- 1V 07 1715
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN INFER
T
MACY ROM a'. � ,
47'W ADAl UR o1r i ft" 0
78••555 M"vNRO M AE)
LA Ql;10TTA C& 92253
LA QmNT—A CA 922153
t ,. .:
(k1,0)564-7820 c°t f1
USE OF PERMIT
P 00+:t Al -VOR SPA �
-'P00!1 atu WA�,K.- ftp! VT INC4.U;fiA1 S SCIWEN YYALd, FOR. POOL R.� UIPMZN7'
POOL ANI,S1OR 21PIS i6,iN)II.4ite Lu
16100049)
PLAN i:MSCK VEX 101 ,1000-439,3 18 $1II11S
CUNSTR.L.ICT1014 FVX 1 31-1000-111£4-tJ o
MWHAV-t1CAI, kiiK POOI, 101a000-421-000 $2410
MUCTRICAL 'iV, , POM, 101-t2f} 34=_000 $43.00
PLd3, BR -10 FRE -- POOL 201-000-41.9.000 927MO
i
1 3 TON IFY.RWY $s FIE,y: VUF. HOS
SES
pE1NSp`
P ,NpNC ..
1;
RECEIPT
DATE t
BY '�
r
DATE FINALED
INSPECTOR
r4�/
INSPECTION ,.RECORD
OPERATION
DATE
INSPECTOR
. r`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 Wail Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final mss-
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 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
Sewer Connection
Pool Cover
Encapsulation
_
"
ZGas Piping
Gas Test
Appliances `
Final
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)
COMMENTS:
.-