RPL (0004-018)LICENSED CONTRACTOR. DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
hapter 9 (commencing with Section 7000) of Division 3 of the Business and
�~`jfessionals Code, and my License is in full force and effect.
icense # Lic. Class Exp. Date
6,561?8 C53 �. 10/31/2i
pate 1 - Signature of Contractor-'
ontractor
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).
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
Sestion 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 STATE FUNI'o Policy No. 094 -00.0006168 -OA
(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
subjectrto the workers' compensation'provisions •of Section.3700 of the Labor
Code/I shall fortwith comply with those provisions:`y'
�Y`Applicant '
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✓spection
,purposes. rposes.
Sig4ture (Owner/Agent) 'f V Date( ) �1
V
BUILDING PERMIT PERMIT#
DATE /f/f p f� VALUATION LOTTRACT
I1�Y
JOB SITE APN
ADDRESS 49-6n WOMMA WAY
OWNER CONTRACTOR / DESIGNER / ENGINEER
T.Dt DEEShMf DEMOMENT CALB)DMIAPOOLS & ISPAS"
P10. BOX 1716 - 74.725 JON'i DRIVE, #dA
LAQ 1NTA CA 92253 PALMDFISM CA 92260 .
(76t1340.9000 CBLN 355
USE OF PERMIT
PAIL.?
Pdoa. A�aD/oR �� �.APD
. }..
PC)OL & SP.A. OI+ILY"-ALA1,Ma-WA'iRIFP.S SHAJ..L BE IN PLACE ^ "It U 000
PRE -PLASTER 1��sP907ION. OF
QU@ IT R
VALUATION 16,000.00 i5
ESTIMAnM COST OF CONSTRUMON K000.00
PElZltW FEE 8UbMAR31
PW4 CHECK FES 101.000.439.318 $111.13
CONSTRUCTION I'EE 101-000.419.000 $171.00
MECRANICAL FEE -- POOL 101-000-421-000 $24.00
LLLCT.RICAL "X -- POOL 101000-420-000 $45.00
PLUMBING'IRE -- POOL 101.000.419-000 127.00
w•
SUB- fOrfAL CCiMMLTL'MON AND PLAN CBECK $378.15
JM3 TIRE -PAID FE'S X0.00
1'MAL ZaERMISl" MUS DUE NOW
RECEIPT DATE BY DATE FIN LED INSPECTOR
INSPECTION RECORD
l'q
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
p 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
Insulation
Compressor
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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
-Gr/
Underground Plbg. Test
Final
Gas Piping
Fi
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: