0206-191 (RPL)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 # LLic. Class Exp. Dat+e� NN 92
614611 C53
l�
Dale'� }� Signature of Contras or.r
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 31'.fi,TEFU14D Policy No. IN61N6701
(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 phall forthwith comply with .th se.pl`ovisions.,
Date."l`.- Applica,t3-',+'06ap^'"':�'-'
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.
Signature (Owner/At "jam"-'' Dater
BUILDING PERM!PERMT"ppy�C Qty
..� R loS4kST'.6:1�
/
DATE VALUATION LOT TRACT,
,, / .fit12,d2t?d3..f3 I S ..
ADDRESS 77-9LRKDO �;>raUiE+•'�' JOB SITE
APN _ ry
OWNER
CONTRACTOR / DESIGNER / EN INEER
a".EDONAl HOW 3,114C
MCU TYREPOOIX A SPPA
77.564 COT:1qM'Y MUi3:'DM S71:EsE 37
PA BOX 1791
.Pxud IT)xparu CA 92.211
};..,.k QtJlw c CA, 92253
(760)360.33585 MIN 1945
USE OF PERMIT
POOL AND/OR SPA
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��ri�at3i�ndSt�.�-5f, .l��it��F• P, -M uFlALLL ER aid 3�1.,,,AG4 P9,1011 TO
9% tJ�tLt,c��aXR1F_RS
IOINT
POOL AND/OR SPA. 113
iia, WA!,r 'm9> w3iiY.f, l�S"��w-W.la�v�LiJ;s d.7.W:G'i
�.d a9dV4c.�S+�
PLAN CRECK N"P
CIO'i3'ifSTRUC:T%ON ME 101-000-418-000 �1�3.t1b3
MECIUMCAAL, PRE —1'C /101.000-4.21400 SX00
ElZC"t`,RICAx.l &E -- POO lel- S�f1-d2d�-E1C�C1 ? BR .GG
P.UNIBIYd0-MI Z Pa*4 ` 161.000 -419 -WO
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WYOFLAQUINTA
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RECEIPT-
DAT%E r Y
B1
DATE INA D
/
INSPE T R
i� ..�'li.«sw..
/
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS'
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
-
cc -Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
– Z (::I '
1
Gas Piping
Gas Test
Appliances
Final
i
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)
5'
sc l (eelw (2x)4
Nqcf,-c-w1us
HACIENDA'S
Lot 15 6-18—Q2
36"
I I
CITY
LA QUINTA
BUILL',-1 SAFETY DEPT.
A""ROVED
FOh; ONSTRUCTION
r/
PAIS ID R -N
CONCRETE AND STAC
S CAPUONV SPILLWAY.
K,\ \!
_�2
I if 13' 8'
S- 9
GREAT
ROOM
SITTING
RAISED BOND BOOVI AT +6'
WITH CONCREIE. CAP.
POOL & SPA SPEC.';
POOL DIM.
24' X
POOL PER.
'.7,?'
POOL S.A.
258 `%0.
DEPTHS 3'-9-
TO 5-6`
SPA DIM.
6' x b/!
SPA PER,
I
SPA S.A.
1,
28 S0. F'r
DECK AREA
638 S-0 F
SCALE :
1/8' = I'
BROOM FINISH COLORED CONCRETF--
DECKING, COLOR TO BE SELECTED
POOL 9'
5'-6"
WET
BAR
KITCHEN
I