0402-054 (RPL)79720 Amalfi Dr
0402-054
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O = ch License # Lic. Class Exp. Date ,
LLJa LO
656113 L5:3 I"1C 1.-14 10 . 1 "2C
oZ t-- Date 1 Signature of Contractor *f
O
J U C:) OWNER -BUILDER DECLARATION
W WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
ce) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)CL Q WORKER'S COMPENSATION DECLARATION
C) Ir I hereby affirm under penalty of perjury one of the following declarations:
Ill Q ( ) I have and will maintain a certificate of consent to self -insure for workers'
X UJ compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q () () I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
IlLO
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 97'Af E COMPENSATI Policy No. 046.6163-2004
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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 3/700; of the Labor
3 Code, I shall;forthwith comply with those provisio`ns. +
Date: 1 ' < r `/ Applicant ,C .z ' C two V
w >
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 authorise representatives of this City to enter upon
the above-mentioned property for inspection purposes.
1
Signature (Owner/Agent) f ? /%* Date
BUILDING PERMIT PERMIT#
04%-054DATE ` ` e` ; (VALUATION 5 . LOT 72 TRACT
JOB SITE L APN
ADDRESS 79-720 AINIALIIi . )MV'. -
OWNER I CONTRACTOR / DESIGNER / EN INEER
P01MMORA.?IOMES HIM CAUFORMA i"0012, & SPAS (T011 MA -14 C(
400 H. NA UKIZ DR SUITE B 103 96.100 AVFWJ:t; 54
I IIt 3..sP.12Ii vT4 CA 92262 COAC:II LLA CIA 92236
(760)398.9222 MIA 00355
USE OF PERMIT
POOL IIIIIIIIIIIIIIIIIIIIIIIII 37
17pI'.. A1+iI)lC R Spt1
' IE
PDOUSPA AJ_4A.M SA1UUF.RS SHAIX 8E IN PLACE PRIO}7 TO I
SIR:-PLA111TER 1H,9PWTI0N,
POOL. ANDIOR ,SPA
17,000.00 LS
e, S,7.&I.tl6tGT9,7.d COST 0Yr CO STiLLSJMIO
,PER,'A iT 1+'1.`31: tM2M. .RY
PJAM4 CHECK FRF 301.000-439-318 $117.00
CONSTRLI'CiION FEE 101--000-418-000 SIBOAD
MECI-LANICAL F'%19 -- POOL 101.000-421.000 £..24,00
iiLECTRIC.FLF, ",-F, — POOL 101-000-4.20-000 '845.00
PLUMBYHO FEE »- POOL
hsl
FEB 1 9 2004
CITY OF LA QUINTA
BUD -TOTAL COMIRLtCi 10M AIS PLAN CTMCK
TOTAL I'A RMT 11711s,4 DUE OW
r
RECEIPT DATES f7 / BY ATE FIEDS I SPECTO
17,{i!?1).00
$393,00
$0400
T-3.91.00
INSPECTION RECORD
OPERATION
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
BLOCKWALL APPROVALS
Set Backs
Steel
Electric.Bond
POOLS - P/ S
-K,
Footings
Main Drain
Band Beam
Approval to Cover
k
r
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
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: