RPL (0210-120)54555 Avenida Martinez
0210-120
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
431056 C 53M.0 (Y 3 11)"
Date 1A f f =Signature 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 114.9 Co o.p Nye Policy No. 10160928900
(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 3700 of the Labor
Code, I shall forthwith comply with those7provisionsF ✓ %
Date: 41;-111'1- 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 $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building arr Safety '
for a permit subject to the conditions and restrictions set forth his
application. Cd
1. Each person upon whose behalf this application is made & each pXon at
whose request and for whose benefit work is performed under or pursOnt to
any permit issued as a result of this applicaton agrees to, & shall, indegnnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null andoid if
work is not commenced within 180 days from date of issuance such d
permit, or cessation of work for 180 days will subject permit to can g ljjation.
I certify that I have read this application and state that the above information is .
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)'> J. riW, •-. 'X Date
BUILDING PERMIT -- PERMIT#
021.0-120
DATEVALUATION LOT TRACT.
A
)/($
f . Z1
JOB SITE
ADDRESS SZ
APN
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
RWIG..,R THOAQSO3 T
004PAR.e"a MYPOOLS fr'C'iWS"TRIX11014
5,4455 AVENOAMARMM
510 (?d:EADTIR :RD
iWNI.,A. CA 572253
R V-1113,PRE IRGS CA 92,26
(76(Y):324.5837 CDIX 97
USE OF PERMIT
fK>01.likf:4~"11OR SPA
N003., SR& ALAg+MWHAPfd ERS SHALL HE M PIAC MAT Pft&P?1At9S'C&9
JNSPFX,'T1M QUIDIRDI T TKINCIL-051JR9, NOT Mt°I,i DED.
Pool,ANDDJOR SPA I ,oiw,dm I'll
5{ .' .[° aM) Ir:0B' '. O i-041i '1+° . 'UC11C. H
16,0300 00
''[ f '{ y • % ' [y
PR1.'{. I a di VII 1ARMA O X19
PLAN CHECK RMe 101_00011439k-318 $12:1103
CONSTR:UC1'10141111 ; 10'!-000.,via- `,r06 $169,00
NW,-4=1MIC,l1L FAE.. - f OOL '101 "000.421-.21X? MOO
EUi:';!'IUC AL 1qk -F POOL 102-000-f,xU-Ctiun $45AW
Pl✓!lF11331A10 I1M.:i--001 i of .0 0041'n-090 7
1
_ 0C 11.
—
CITY OF It.A QUIN
FFI}N AvNy Cp/E' DgEPyTgT,+A. 7 7 pr - ' }
P., 7 +t.ar3"J. rAl, O i .J. JI, 41.:t. J.,9,'1 N % L D .' A.em7l Ci;(.:L IX.
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Y=3 °KRZI 1WD 11 3
$0,00
oT,4;>l,, I afire .Du ri wow
$407,
RECEIPT DATE BY I_ DATE FI ALED INSPECTO
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 t
Exterior Lath
rywall - 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
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
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:
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6' Spa Raised 12"
FA/C
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