RPL (0004-271)"CENSED CONTRACTOR DECLARATION
I hereby a er penalty of perjury that I am licensed under provisions of
Chapter 9 ding with Section 7000) of Division 3 of the Business and
Professiona�a nd my License is in full force and effect.
License # Lic. Class Exp. Date
6512059 - C-:13 0"//31,2,VL-
n
Date Signature of Cotractor T77 "n ^ `==r-^-+�---
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
Sec '& 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 1g)N7' CoMp INS Policy No. fhN9909347301
(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 pro isions of Section 370.0 of the Labor
Code,Ihs ramforthwith comply with those rovisions. }l
Date: N ), 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°+inspection purposes.
Signature (Owner/Agent) ateDa
,.I I
BUILDING
PERMIT PERMIT#
r
DATE �A�, LOT Ot4-271. TRACT
h� VALUATION �,
.�
v
.�
JOB SITE I �"�f
APN
ADDRESS��
OWNER ,
CONTRACTOR / DESIGNER / EN INEER
ROHM FEURY
C;t'imillii POOL CONSTRLUC"I ioyl, me.
794985 MRION
76-710 LA PAIlkh DR, 1A C2VWfA
LA QIIWT'A
CA. 92253
PAU413R&FIRT
CA 52261
(160)3+60-6602
CB1,6
1844
USE OF PERMIT
POOLM.D1011. SPAS
P[OC��On] I([:y+�fr.�tppNitAA(9O{Y��fLY�•je�lA�tL AryR(:MA TlARIZIRRS SHALI" BE IN PI -,ACE x+ T
PRIF-PLA l.L' R 47`71�P7. C d IO
'
VALUATION
82,000.00 L-3
a
ES'4MATC1i CONT OF CONSMI 3110H
92,0M.00
VF,1tMU FRE Si:TA&AARY
PLAN CHECK "X
101.0100-439.318 00103
COWSTRUCTION FEE
101-000-418-000 $559.50
MECHANICAL FEE -- POOL
101.000.421.000 $14,00
fAV XCTRIC,AL FIT -.• PGOI,
101-000-420-000 $11.00
P1LlIAdt3 NGFER.-POOL
101.000-41.9.000 $27.00
SI MIAL CONST`RU0T ON AND PLA14 01MCK
LEM PRE -PAID FEES
f�
'` #$0.00
DOTAL FEIRKU :07KES DUE NOW
1 P A 7.*3
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Backs
Underground Ducts
ms & Footings
3 Grade
Ducts
Return Air
St I
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
S
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
COMMENTS:
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)