0010-056 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of .perjury that I am licensed under provisions of
Chapter (commencing with Section 7000) of Division 3 of the Business and
l= a�ofes;*'176als Code, and my License is in full force and effect.
N `icense'.?R Lic. Class Exp. Dattey.,
0612.9 1 t1iS 1 l�C
Date / 0 ' ? 1� ' r 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 insurance carrier & policy no. are:
Carrier Policy No.
3TATF, FUN �6A IbR i400�1�l1 �t�
(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 Applicant'"' 7Y__..._ �_._....._._
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 property for inspection purposes.
Y - ,._ w
Signature (Owner/Agent) 4L `�- =—_ . - Date
BUILDING PERMIT PERMIT #
DATE VALUATION LOT 0010.0-� TRACT _
i
r. t c IV)
JOB SITE
APN
ADDRESS
"191-74.5 CEMMO
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CIRNITURY movrrlu. CMMKfJNUIES
W WaR. A.POOLS S.1, WAS
1535 30, STK -6200
74.725 Mgl VRIVE., IkPs
88111 I: ER,A APJDR40 CA 9=9
PALM DES"KtT CA 92260
(76"40-9000 CB1# 355
USE OF PERMIT
P001, AND/OIC. 11-341A
POOL. A SPA ONLY>.Ai ltRM:3/'LtAR3t.1N R.s SHALL FIE IN P_1 AC .:.ATi 'PRY,
PIASTER INS.1��.,�':TION,POOL, EQUIPMENT VN=SURZ 19 NOT INCLUDED
IN THIS Pk'18MIT
POOL AND/OR, SIPA 1 d800.0p ,,14
3z'D COSI' OF CORS RXICi'.LON
PI M11 clq.zC:K VEY 101,000,439-319
CON!.',T'UCT1QN1t'EE 101 -000 -4118 -ow $171.00
MIX,.KAXICAL FEE • - POOL 101.000-421-000 $74.00
YLEXTAICA.1, M Ye POOL ' 101-013 42.0-000 $43.00
M{iMl:►RI10 :SFA •- KXXI 101 -OW-419-000 $27.00
t
6
A -'
� IAESS I°Rz;ePfiJD:T�;&!
$0100
OCT 10 2000. Wr -PEMMT IMES D E NOW
Ul LA �`W'
RECEIPT
DATE' E f
BYE 1
DATE FINALED
INSPECTOR
Jll
i
INSPECTION RECORD
, f;40PERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts i
Slab Grade
Return Air i
r
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
r.
Insulation
Vents
Fireplace P.L.
Grills i
Fireplace T.O.
Fans 8 Controlsj
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
1
i
i
Final
Final
POOLS - SPAS
'
BLOCKWALL APPROVALS
Set Backs
Footings
Steel
Electric Bond 2 e�
Main Drain 2 l®
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final.
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final I /
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
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)