RPL (04-7945)P.O. BOX 1504 ��GIGI
VOICE (760) 777.7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: o14- %9 14 5 Date: —�%
Applicant:
Applicant's Mailing Address:
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S 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 Class License No.
Date Contractor.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
th
applicant to a civil penalty of not more than five hundred dollars ($500).):
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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. B.& ffis reason
/ / WQRyt'ERS' COMPENSATION DECLARATION
affirm I hereby arm under penalty of pe ryorSe of the following declarffi`ons:
_ 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 and policy number are:
Cartier Policy Number
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 ree that, if I shout ome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
1forthwith comply with those provisi
ate — 7-'`ritapplicant V
WARNING: FAILURE TO SECURE WOR R OMPENSATI COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED T S D DOLLARS 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE NTE EST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lenders Address ✓`
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Ouinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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 1 have read this application and state that the above inform ion is correct. gree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to e r n the qve-mentioned orooertv for inspection nii.nneac
ate / r" :t -V J
' nature (Applicant or Agent): / �;
----------------------------------
Application Number .
. . . 04-00007945
Permit . . . . . .
BLDG POOL PERMIT
Additional desc
Permit Fee . . .
252.00 Plan Check
Fee
163.80 -
Issue Date
Valuation
. . .
. 25000
Qty Unit Charge
Per
Extension
BASE FEE
45.00
23.00 9.0000
---------------------------------------------------=------------------------
THOU BLDG 2,001-25,000
207.00
Permit ... . .
MECH POOL
Additional desc
Permit.Fee . . .
24.00 Plan Check
Fee
6.00
:Issue Date
Valuation
. . .
. 0
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 9.0000
EA MECH FURNACE <=100K
9.00
Permit . . . . . .
ELEC POOL PERMIT -RES
Additional desc
Permit Fee . . .
45.00 Plan Check
Fee,.-.
11.25
Issue Date
Valuation
0
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 30.0000
----------------------------------------------------------------------------
EA ELEC PRIVATE SWIMMING
POOL
30.00
Permit . . . . . .
PLUMBING
Additional desc
Permit Fee . . .
33.00 Plan Check
Fee
8.25
Issue Date . . .
Valuation
0
Qty Unit Charge
Per
Extension
BASE FEE
15.00
2.00 6.0000
EA PLB FIXTURE
12.00
1.00 3.0000
EA PLB WATER INST/ALT/REP
3.00
1.00 3.0000
EA PLB GAS.PIPE 1-4 OUTLETS
3.00
Special Notes and Comments
POOL & SPA ONLY. ALARMS/BARRIERS
SHALL
BE IN PLACE
PRIOR TO PREPLASTER
INSPECTION.
EQUIPMENT ENCLOSURE NOT
• INCLUDED IN
PERMIT.
Fee summary
Charged Paid
Credited
Due
K'.-----------------
--------------------
--------------------
Permit Fee
Total 354.00 .00
00
354.00
Plan Check
Total 189.30 .00
.00
189.30
Grand Total
543.30 .00
.00.
543.30
M
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} �• BUILDING & SAFETY DEPT.
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APPROVED
• 'FOR CONSTRUCTION
! u1�,t
DATE BY
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710 eliAb
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POO
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CITY OF L~��" nB-CONl.RAClORU UST
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--- � � '
---'This form shall be posted on the with the Building Insdection Card at all times in a c6nspi�uous plac"e. Only p^noonaap^-hn0-onthis list. ortheir ar�'l»yoesare authmiomd' .'
~ ..list-�-��-._prior `. ` f work and/or woidanc�
^~. .~�.~. '., changes to this —'- approved by - --. vo work: onJy m '
t. For each applicable trade'. all information requested below be completed.by
.................
.X.:
Company Name
Classification
(e.g. A, B, C-8)
License Number
ixxxxxi)
Exp. Date
(xx/xx/xx)
-Name.
Je.g. State.Fund, Calqomp)
Policy Number
-(Format Varies).
Exp. Date
(xx/xx/xx)
License Number
Exp. Date
eo
XXX
36