RPL (0402-065)55455 Medallist Dr
0402-065
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that, ham licensed under provisions of -
Chapter 9 (commencing with Section 7000) f Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
C55 19L C-8,1 I Q13112C
Date Signature of Contractor
OWNER-BPILDER.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
1' 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.
(') -1I have and will maintain workers' compensation insurance, as required by
Sectio"n 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:
,Cartier OTATEC°.OMPERSATI Policy No. 046-6168-20041 -
(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'ihe workers' compensation provisions of Sectiont3760 of the Labor
Code ,l -sol forthwith comply with, those provisigns.,
Date..;? ! Applicant
Ad<f a...: -^r%''- ?r-"
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.
f 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
p,tiie above-mentionedproperty for inspection purposes.
Signature (Owner/Agent) f Date
BUILDING PERMIT PERMS # '
DATE P Jr/!! ;
VALUATIONe LOTJOB SITE
? TRACT
ADDRESS «s i iSfd e{.,i° i APN
OWNER CONTRACTOR / DESIGNER / EN 1NtEyER
e ahlsla+8T.raEV 1• CAUMI: POOT-O 0PA8 CF0PMA1,, CCr U1.
1 314i fNi it i' 67 1 b L ` 96.100 AY .MJF,541 t
,YCT.i?1fi 2 M, 33477 COACBE11TIA CA 9223 ti
USE OF PERMIT
PO 01, AND/OR &VA
e
POOiJ;;il'4WATE FEA.TUR14 SEQ AFAR
lP UOR. TO PRE•PLOXTE3R INSPECTION
POOL Alt WOR SPA
SHAIX BE 1N
M000100 I
MIMATED Con or, cams'Inumom
1U.M. A2 ( 7i SCTMM1I PY
MAN UHRC K MR' 101-000.439.318 9122.85
CONSTRUCTION FEZ 101.000-418-000 2129.00
iMEC:I"1ANYK.''.F1I., FEE -- POOL 101-000421-1000 $24,00
&.ECT PICA.L FLEE —'POOL; 101-000-.420-000 $45.00
.PLU£t9t3DY0 FEE -- POOL 101-000-419-000 S2 t.OL
JU FEB 0 9 1004 V
r
CITY OF LA QUINTA
FINANCE DEPT.
F31331-7ov& t`:aww '.'C'.E3.iTti:'. lokxT.
LESS PRE -PAID £'`6 x,`9
TOTAL F-FARWITET,S DUT NOW
RECEIPT DATE I.BY I DATE FIVALED , INSPECJQFj-. i.
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
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
Z9 p
Gas Piping
Gas Test
Appliances
Final
/
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: