RPL (0101-078)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
Signature of Contractor 01 _;a
OWNER-BUI6ER-DEEL-AKATION
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:
Carrier Policy No.
(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
S
to the workers' compensation provisions of Section 3700 of the Labor
e I sh II fortyi�with comply with these proy�slons. „ � '
Applicant-•• �• — F
Warning: Failure to secure WorCcers"` Compensation coverage's unlawful and
shall subject an employer to criminal penalties_aitd>C III fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3.706
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 hid'.
application.
1. Each person upon whose behalf this application is made & each person
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,wlthln;,a80f;days from,date of issuance `of such,{
permit, or ce's`sation of.•work for lif days will subject permit'to cancellation".'4 '
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 ab&e-mentioned proper{' _y o inspection purposes. s
Signature (Owner/Agent)-"- r ^" "Date /-2s
BUILDING PERMIT PERMITk ' �1 / .. :' L'
L.:
DATE VALUATION LOT Q��.Qiyr-�'i TRACT
M 5-04 0-
JOB SITE
APN r�
ADDRESS: 814M.ydpf70YL<AL
s. .'•c„`.I ,
OWNER
CONTRACTOR / DESIGNER / EN _INEER
CA 92:8"
LA Q'MT A, CA 92250, '
s '>
USE OF PERMIT
P4,70L., &:SPx° GN1,Y,,AUk1'ZM"+lff3AARJXRS S"KA4:4, :f•.'.ly W PLACE AT PRF '
PIA.811R,r'aNf3PECTEr. ON. POOL w.;QU9:F!M:ENT "RICLOU N, is NOT INCd.•UDRD
DIR THI'S PURAUT.
POOL MUM SPA 15AD.0114 LS
MAIED C.ov"r 01i, COMi"? JC°iTON
;Xh"U
PLAN 01JEC'K 1,79E 101.000.439-�3lie $10,31s
CCRIS'i'RUC'8'ION PER 9 I01-•0012•418-000 $162.00
MECHANICAL E -- POOL, 101-000-4-21OGO 524.00
..
PLEC"I'RI1'a't'e.L FM' - POOL $45.00
'
i'14J ftrf11G FEE -^ PoOL 101-000-4 0-000 $27.00
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VIS CON") IOK AMMI KANT CHUN, C
$36:3.30 -
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LWS PRE -PAID MIS
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RECEIPTDATE
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BY j/
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DAT L
INSPECTOR
t • /
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
Footings
Main Drain
111
Bond Beam
Approval to Cover
Equipment Location
Final
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
e
/f
!/
PLUMBING APPROVALS
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
Gas Piping
Gas Test
Encapsulation
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
tility Notice (Perm)