RPL (0303-230)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
573948 C-513 7,131193
r
1
ate l Signature of Contractor
y
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:
O I have and will maintain a certificate of.consentAfo`selt;nsure-for•w�orkers'
compensation, as provided for by Section�3700 of the Labor Code,' for the
performance of the work for which this permit'is issued. 1 !
( ) 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 VI'ATH FUND Policy No. 229-022036-209
(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 shallaforthwith comply with those.,provj~ ions.
Date: ~ f Applicant 4 C�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby mA to the Director Building and Safety
for a permit subject to the conditions and restrict ons seforth on his
application. Y`
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation:.,
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) L ! f Date
i
PERMITJI
i, BUILDING PERMIT to
`{
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DATE' !` VALUATION %V OWAX$ LOT, r,,'TRACT
i +
JOB SITE
ADDRESS 81-175 Nt�TIONAL D Rr
APN _
OWNER
CONTRACTOR/DESIGNER/ENGINEER
DON FIUCE
RMO I>OOLS
81.175 NATIONALDRIVE
81.018 UUM WAY
LA. QiI:INTA CA. 92253
INDIO CA 92201
(760)347.1617 C #LR 2638
USE OF PERMIT
ROOL ANDBOI<"t, SPA
PTJKyUNPA. ALH.K?AW0P' ' Vk; L!ZH.6}.!_,llw.011, I PI FLa%l.Z,AA ' C*1.7fx,K
iPti P.WTION. EQUIPMENT ENC OSURIF NOT MCLtJM
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COST 017 CO1�I.S"I� UC'.Q�J.IP�T
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.C1C'i2S.IVJJ•i At�AT fA'IJ�.vdAwd.Fi.ECS.
PLA14 CHECK FEB 101.000.439.318 $1K93
CONSTRUCTION FEE 101-000.418-000 $ZFA.50
MECHANICAL ITE -- POOL 101.000.421.000 $24,00
ELFZTRIC:AL "X, •- POOL. 10i. -M"20-000 $45.00
PLUIJ[} rHe ME -- Pool, 101.000,14.19.000 t2Y,tild
SUB -TOTAL COXSMZU•Cn0K AND PI" CHECK
$565.43
LES3 M -r -AM FM9
$0,00
TO'.RA1, I'`-O:1iW 3+'EES D'I7 K NOCK
S565A3
RECEIPT
DATES [ d /�
BY
DATE FI LE
INSPEC O
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel 14 4:2
Set Backs
Electric Bond
Footings
Main Drain
Y Bond Beam
Approval to Cover
Equipment Location
Underground Electric 19
Underground Pibg. 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
Final
Utility Notice (Gas)
Y 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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COMMENTS:
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