RPL (0005-232)53765 Avenida Madero
0005-232
LICENSED CONTRACTOR DECLARATION
I her: y+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 !
Date ' Signature of Contractod
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 is4not:,lntended 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 STAT'I CON. 1-k7J FM Policy No. IS42457
(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 thatPl should become
subject to the workers' compensatio qj `provisions `of sdi'Wo 3700 o the Labor
-
1 sh II f rrthwith comply with t bse,p _
Date: Applicant—
Warning:
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit . subject to the conditions and restrictions set forth on his
application. ., .
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property f#inspectioif'p r( gtC.
Signature (Owner/Agent)G ! Date
4
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 000-2`;21 TRACT
05/184M 1.I3J 1 Bi 97,U 19
JOB SITE Tt
ADDRESS +,r.`t.iarpi.I ,i1 DVM0
APN
! 774-442-013 '
OWNER
CONTRACTOR / DESIGNER / EN (NEER
rdc T.AR SC!OTr
1q0R1WWFM-SOtMiWEVTD.1 :1 WJ
71504 A. C0U_TTrRYf_ UB DR. 113
77-W- A COMMYRY CLUB DR
PAUA DL STERT CA 92211
P". DERM CA 92211
.(760)408-3495 COLO 6133
USE OF PERMIT -
POOL MWOIi.111vIA
POOL i$'SPA 0,Ni.Y-AIA8tA+ Y8A 1R1FRS SFIALL HE IN MACE E .AT PRIG
PLASTER INSPECT'ION.P00L EVIPMENT ENCLOSURE 19 NOT INCLUDED
114 ' HIS PF1'tldiIx
POOLANU/OR NPA';.` :. 9.swo0LS
E91 -MATED C OS17 O1+' COMS:d'IN'TJ'MON •
911500M
PFAtW FEE 8UM-M RY N
PLAN CHECK FLE 1 C3i •ilfJp-X39.31 d M05
C014ST11,UCTION PZ 141-000.419-000 $117.00
ME, CHANICAL FEF -- POOL 101-000-121.000 $24.00
ZL ECTRICAI.. FZZ — POOL 141-000-4.20-000 $45.00
1PLUMBIM FFR -- P001. 101.000-4.19.000 $"_00
HIM -TOTAL CO1bTML1C;7°IOL>3AND PLAW CBECK
$289.05
LESS PREPPMS
M00
eRWIT ++
MMM
RECEIPT
DATE
`B
D FI
INSPECTOR
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 S Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
5
Footings
Main Drain '
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test vu -
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
r
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
.NO EXCEPTIONS
T
91
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3'a P•
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
A
BY