0004-120 (RPL)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
X72850 C53 11TC�;; 06i/3`71?C
s
Date ��l�Jr � 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'insurancecarrier & policy no. are:
Carrier T FRF-NI014EMPLOYE Policy No. WC W305602 2
(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 Those provisions.
Date: r//;) Z4.. Applicants
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 authorise representatives of this City to enter upon
the above-mentioned property1for inspection purposes.
Signature (Owner/Agent) �C--1�- Dated
BUILDING PERMIT PERMIT#
DATEVALUATION LOT 0004-12
$10,000.00
JOB SITE
APN
ADDRESS 79-607MO OG GLORY
OWNER I
CONTRACTOR/DESIGNER/ENGINEER
WO= DEVELOPMENT, LtJC
GAT: USO POOL. PL'C1MMING, BTC
74-333 HWY I I 1 2TIS 103
667 EETJOBNEE, RD,
PALM DESIKU CA 92260
PALM S:P12NGS CA 92264
(760)327-7592 CBL!# 816
USE OF PERMIT
POOL. AND/OR bSPA
POOL & SPA ONLY-.A..L ARMS/BARRIERS SHALL .BE IN PLACE AT PRE
PLASS R. INSPECTION,
POOL Ali)WOR SPA 10 000.00 LS
EST)MAY" COSY' OF CO:['i'S1' UC17ON
101000.00
PKT M r n.R SUMMARY
PbM CHECK FEE 101-000.439.318 t"'i6,05
CONSTRUCTI OM FEE 101-000-418-000 $117.00
MECHANICAL, b7E -- POOL 101-000-421-000 $24.00
ELECTRICAL FEE -- POOL 101-000-420-000 $45.00
PLUMBING FEE -- POOL 101-000-419-000 $27,00
SUB 71 CONST.F.2TJC"I ION AND PLAN CHECK
$289.05
LESS PRE -PAM FE .'3
$0.00
.4 A') 11,b7` ..P)Uz M M. S .1 1E NOW
.�--
RECEIPT
DATE '
'BY:
DATE FINALED
INSPECTOR
�_,
INSPECTION RECORD
OPERATION DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
nnrmrall _ Int I nth
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents .
Grills
Fans & Controls
Condensate Lines
Final
POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond AIM
Footings Main Drain _! '
Bond Beam Approval to Cover
Equipment Location
Underground Electric _A
mnat
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
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Tema. Power Pole
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
S'- Z2 -