0205-054 (RPL)LICENSED CONTRACTOR DECLARATION
1 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
/6ate5"' .3` 0Q2 Signature of Contractori`"'t
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.
X( I have and will maintain workers' compensation insurance, as required by
Sec ion 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 STATE $9;5ND Policy No. 0461046,701
(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
�ode, shell forthwith comply wif�qthos , provisspas.
Date:" �"
Applicant -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and'Safety
for a permit subject to the conditions and restrictions set forthi on his
application. Pte,
1. Each person upon whose behalf this application -is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of, such 2
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all"City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned proproperty for inspection purposes. (`
Signature (Owner/Agent""� �'� Date'•' _$mo ^
BUILDING PERMIT PERMT# -
01 ()&4
DATE VALUATION LOT TRACTJOB
SITE
ADDRESS 774M.5LArkP'-C� 100 CUE=
APN r
OWNER
CONTRACTOR / DESIGNER /EN (NEER
SM09A HO6 s, We
bCTLTfYRy, }''t.iULS & SPAH
7'1.504• COUNTRY ILUM JA VE %ME37
PIC). play. 1791
PALM :L1RIM—C CA 92211
LA. Q'0W-N CA P?. ca:r
MUH 1945
USE OF PERMIT
111001114T3)AM VA
P(n)I.fSP4.},i,i"Maft'ARht.KM SHAW,. BP_ 3'14 Pd.,AC-PRIOR TO
POOL ANN0.11 SPA 12
ESTMAT COST 011, �.ON"Uri2LiC'�'��(:�aY'
p 1 i�s� � g g
�y�+�g�" sy+ TRARY
T USN CHECK FRIT,
CONSTRUCTION i101 X01-gOI?�i i�-UC3� �OG.h.no
MECHANICAL RX --POOL, 101.000.421¢000
L LMTRIC„AL.Y.I,- POOL 101,-00041201 0OO ��.f1f►
xPt. p4R11+1C Fa.:. POOL 101-000-410-000
1i.0..'�• `'Vr1%CHECK E 1
p7ffdvff =1 5 DUE Now
M0A u 3 2001
WYOFLAQUINTA
FINANCEDEPT. '
;4
,RECEIPT
DATE � * � �
•BYE, � �
DATE FINA�ADa
INSPECTOR
G'/
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 Wail Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
zr
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_T%2
Underground Plbg. 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
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)
44
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IF
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
-APPROVED
FOR CONSTRUCTION
sir
t ,..
CITY OF LA QUINTA
�F o BUILDING � SAFETY DEPARTMENT
M of ,777-7012
INSPECTION REQU
777-7153(�at :0= 9
,
Co races Q T-
POOLS SPAS
e it Nin
%RX
P
IN CONSPICUOUS PLACE
I PEG
T SIGN ALL APPLICABLE SPACES • I
ID ; _
ARIVISBARRIERS SHALL `BE
OR TO PRE -PLASTER
YiXO
ION DATE INSP
TEMPORARY POWER
SETBACKS
U/G PLUMBING /WASTE
U/G ELECTRICAL/ GROUNDING
FOOTINGS / STEEL
CONCRETE SLAB
DO NOT POUR CONCRETE UNTIL ABOVE SIGHFn
r
a
nuuun rLUMUINU I
ROUGH MECHANICAL
INSULATION f
. COVER NO WORK UNTIL ABOVE SIGNED
INTERIOR GYP. BD. DRYWALL
EXTERIOR LATH I
GAS TEST
SEPTIC ABANDONMENT
SEWER CONNECTION
SEPTIC / GREASE INTERCEPTOR ,
MASONRY INSPECTIONS
FOOTINGS / STEEL ,
BOND BEAM
POOL / SPA / WATER FEATUR INSPECTIONS
PRE-GUNITE / SETBACKS s QZ
U/G PLUMBING
U/G UAS �
U/G ELECTRICAL
PRE -PLASTER ALARMS / BARRIERS
FINAL INSPEC 10 S
TEMP. USE OF PERMANENT POWER
ELECTRICAL
PLUMBING
MECHANICAL
` PUBLIC WORKS DEPARTMENT
COMMUNITY DEVELOPMENT DEPT.
FINAL / JO ,CO PLETED
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