0207-218 (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 # Lic. Class Exp. Date
656128 C53 F4111 b' '1"0!311/as
DateSignature 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 OTATEtr;OMPEMAJI Policy No. 0460006169-01
(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' compensationprovisions of Section 3700 of the Labor
Code, I shall forthwith comply with 69e provisions.
Date: -;'>r / ;&a 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 $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City .to enter upon
the above-mentioned property r inspection purposes/.
Signature (Owner/Agent) A �Y Y9/ ... Date
f?/9
• P
_ . .
- -" BUILDING PEAM17` PERMIT#
DATE w 'ln VALUATION 17, -9. 7 . LOT TRACT
ADDRESS 5ti-Mo1�3'.�'l�lrLiAMOMMA IA.. JOB SITE
APN - -
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
.LYlLyRt8i dZ Ma
CA715POyLCPOL$ & SP0 CYOP AIpCU
52-196 AVENI AT-401TILMMA
74725 JONI DRIM, SIATE Ot,
L& Qj.IWA, ICA Q2253
muk% D! gym i. Glti 922601
(760)34,0-90150 C...B1.4 0055
USE OF PERMIT
P0 On �am/on anm
MY 3'i`:h,3dOAD..A.LA>ItM9lE,/af;Tidl% S SHALL BY 114 PLACE AT
I MPLA.SiTI&R. iiQBRASCT1014
5 FT. WAIAL IS,00 LF
VALUATION Is
F�A7y=,^d.<1.7,3,.D COSMOF 0.iVSC17ML. (7110Ay
3 . A-59.75
rL.f l CHP—Cru 3? 101. ;CS{)0�4 X31 /3 S3? S
%;ar�+3STit:ti�'I'dCFAi 10'1 �QQw-�i 1 f'�-°�I10 �Ib9.31[l
��`
MECHM4' CA.€.IFER --11001. 101,Q00.621.000 $6S.YiO
l.,d,3:C; �!'iF.7t;./#I. ra'�i$ �* EaU�3':i. 1 �� ••iJt��-�i'��Qi.1� '�"i!IF. ®0 ;
PLUMBING V071-- Pool, 161 -om4"J 9.000
U[—C.1.-1y
OF LAQUINTA
DEPT.
FINANCE
_.
SM -TOTAL OTAL CONWITUC1104 A161i? PLA14 01-W1G.
w '
RECEIPT
DATE f
BY
D V FINp�FB
INSPECT
OF
e -w
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
C
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
Gas Piping
Encapsulation�6
j
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Votiage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
CITY OF LA QUINTA
BUILDING & SAFETY DEPARTMENT
OF
777-7012
INSPECT.LON REQUEST LINE
r <b777-7153
Owner M/M-->nTNT7i:F,R
Contractor Cbl.A.lNfA P0016S R SPAS
Permit Number (11707-7,18
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS 52-196 AVENIDA MONTEZUMA
POOL, SPA, BBQ(ANSI Z21-58-1995),15 L.F. 5' BLOCK
WALL, CITY STANDAD. ALARMS/BARRIERS SHALL BE
IN PLACE AT PRE -PLASTER INSPECTION
TYPE OF INSPECTION DATE INSP.
TEMPORARY POWER
SETBACKS
U/G PLUMBING / WASTE
U/G ELECTRICAL./ GROUNDING
FOOTINGS / STEEL
CONCRETE SLAB
DO NOT POUR CONCRETE UNTIL ABOVE SIGNED
ROOF NAIL/ PRE -ROOF .
OKAY TO WRAP
FRAMING COMBINATION
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH MECHANICAL
INSULATION
COVER NO WORK UNTIL ABOVE SIGNED
INTERIOR GYP. BD. DRYWALL
EXTERIOR LATH
GAS TEST
SEPTIC ABANDONMENT
SEWER CONNECTION
SEPTIC /GREASE INTERCEPTOR
MASONRY INSPECTIONS
FOOTINGS / STEEL
BOND BEAM
POOL / SPA / WATER FEATURE INSPECTIONS
PRE-GUNITE/ SETBACKS 02—
U/G
ZU/G PLUMBING.-
U/G GAS
U/G ELECTRICAL
PRE -PLASTER ALARMS / BARRIERS K
FINAL INSPECTIONS
TEMP. USE OF PERMANENT POWER
ELECTRICAL
PLUMBING
MECHANICAL
PUBLIC WORKS DEPARTMENT
t COMMUNITY DEVELOPMENT DEPT.
FINAL/ JOB COMPLETED
ALL CONCRETE FLAT WORK SHALL BE PLACED A
MINIMUM OF 2" BELOW WEEP SCREEDS. o
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