RPL (0403-257)LICENSEDiCONTRACTOR 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
B I -TIC 18/31/04
/04
Date �' Signature of Contractor
f ..._.,,
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:
Carver STATE FMID . Policy No. ISM5,57•®3
(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.s all forthwith comply witDAhose ovi ions.
Dat :4' t Applicant—L
✓ (z.-— �}
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 proertyr or i spection purposes.
Signature (Owner/Agent) DateOr e
d
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0403 -MSF TRACT
JOB SITE
ADDRESS ;f {y ,�_yy��yr��
✓
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PONNI'JU, FW ANCE
PACof6if: l:iom
PO DOX 134
37564 h CO MY CLUB DRIVE, MTE 113
LA QTJ!t1 I'A CA 9225:
PAL11/.t DEMT CA 92211
C160)408n3495 Mzvt 29513
USE OF PERMIT
P001:—P,N,r.)!OR SPA
POOL &Slag. ALAh,IWBARR.IERS Sli. kLL BE AN PLACE PRxUR TO
1'REPUMTER DISPECTTOH.
POOL AN T-4011 SPA 1%000.00 1.3
39mfX,A'VED COST OF CCJiaFVIRTY `14. N
A �pi46ei7r€10
PM' TIT tri+ E' pd1MARY
PLA14 CIIFCX FEE 141-000-139'.5183 sr. .i5
e;t; NSTRUC:T IO14 FEE 101-000418-000 R335.110
MECHANICAL FEE 101m000-421-000
i► ECri' AN11CAL FEE — POOL 101-000-•42.1-000 $24.00
lsMM1.lCAL FF..I, -- POOL 101--000A42,0-000 Sr45.00
PLUIa/BINO Fi"L+ – POOL 101 -!,'J0 -419-00t3 $27.60
ALM . r<Yr L C;ONYf'F2CFC`MON.MD PLAN CMM
$31835
0 NOW
MAR 2 62004
CITY Of P_:. "'," r FA /
RECEIPT "—"DATE"^
------t
BYay,4 --TDAIUINALED
INSPECTOR
K
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 - H. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
w
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
-74
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
xv 67Y
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)
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