0101-262 (RPL)H
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LICENSED CONTRACTOR. DECLARATION
under penalty of perjury that I am licensed under provisions of
Imencing with Section 7000) of Division 3 of the Business and
:ode, and my License is in full force and effect.
Lie. Class Exp. Date
X51 A x+11 t" :3 ti > + (33431 /2f
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'Date2� Signature of ContraCto� �-- "— ,P ---
P _....-
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&RC. 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:
Cartier Policy No.
"h+y11,;,1,AM+SDt,3R69 DIV. '�'�
(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 comp" ilh those provisions",
Date: w_" �" + Applicant �a� �5,Z=
Warning: Failure to secure Workers' Compensation coverage is unlawful and
sha"I 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 attomey'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 a
any permit issued as a result of this applicaton agrees to, & shall, indemnify.
& hold harmless the City of La Quinta, its officers, agents and emp o S.
2. Any permit issued as a result of this application becomes null an 111
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 d iys 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 �roperty for inspection purposes.
Signature (Owner/Agent),�-3',' �— Data!Q�
BUILDING PERMIT PERMIT#
DATE f VALUATION LOT 0,10 -2ffl TRACT
JOB BITE
APN
ADDRESS
c ! ■ py yy 1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
5 5.645 C-11 s IRI MULS
P,0, BOX1791
.(,H QUI T/'% CA 9225.3
LA QUMA CA 92253
(760)360-3565 MUH 1945
USE
yO--F+ry�P//ERMIT yyiidv� SPA d'4XIL ?�3J.h D/aR. E�.C`A
POOL4, SPA. ONLY-AJA12.MSIDAdtlJERv SHALL kit", IN PIACY AT PRE
PLASTRR IT'iSF'g,(;'1'ION.POOL EQUIPMENT R>rsOL(50URE ftl, NOT fRUt'tJDED
IN THIS bb[:RNIT
1100LANDJOR.SPA 20000.00 is
nMJ!'klrm C109T OF OO.N110IM')t'ION
20, ,t1f 1
PWfl/!rF b°EE 9€.i1M1tRY
P1,AN M-ItC A FEE 101.000.439.318 9134M
CONISMI.U(:TR N iYi'.I£ 101-000418-000 $30.00
PIECf•1ANTC.A6 FFE •- FOOL 101.4K)0- 421.1000 $24,00
F;l. EC:TIUCAL. nE n- POOL 101 _QQt. d2G-000 $45.00
f'3.�L1' tl ll+bf4 l°�, 1'oou 101-000.43 9-000 $ i.00
u
2antlLi��C1i�.l'}.YtVFG��i€tAt�,1JfI�1�11tYi4:1�.
1ZOSY 1'fiE-PMD "M
$0.00
r LA
1E UEE NOW
RECEIPT
I DATE t'; J
rBY� y-7
DATE FINALED
INSPECTOR
JNSP ECTM RIC ORD
OPERATOON
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
'!lacks
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
-- POOLS -SPAS
Steel
Electric Bond_
Main Drain
C-'t0CCaCIU, LPPRc VX
Set Backs _ v
Footings
Bond Beam _
_
Approval to Cover
Equipment Location
_
Finall _
_
Waste Lines -JY
Underground Electric
Underground Plbg. Test __
I Gas Piping
Gas Test
Final
_
5
_Electric
Heater f=inal
Water Piping _-_
Plumbing Final
Plumbing Top Out
_ ^
Equipment Enclosure
_
Shower Pans -
_ _
_
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
_
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELL.ECT=ALS 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)