0207-095 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under prove ions 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
614611 C53 €3/3_1/2C
Date�%- Signature of Contractor
v. _ '00,.
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). r ,
( ) I am exempt under Section B&P.C. for this season
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.
Se( ) I have and will maintain workers' compensation insurance, as required by
tion 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 STATEFUND , Policy No. 0461046M
(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 shill forthwith comply with those provisions. r,
Date: ��� _' -Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for it permit subject to the conditions and restrictions set forth on his
application. *.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
&hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance ,of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is.
correct: I,agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)Date
/r L. Date
s w
BUILDING..vP.ERMIT... PERMIT"
DATE VALUATION g,j `LOT % TRACT
JOB ADDRESS .9.! 1'65 �.,x�J4���s o cow =
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'77-564 COUNTRY 0,1MAME:I�'R? 1:37
:r o, BOX 179''
PAU,t:.LiE tom. °t' Cly 92211
LA Q1,TXxA CA 922.1
(760)360.3mMIN, 1945
USE OF PERMIT
P 0 QL P111MIOR SPA
SHALL R"r,":.IN PIACE MOR O
,
1300ifdAND,0A SPA V%000,00 LE
l�. m"XIET., Cour o1. cors cauC:"non
1.5.000M
PlaAN t'NZCK FF'.9 101-000.4:19••31$ $105130
C014ST1,WC d9OU IM"19 101.000.418-000 $16100
NECHANICA.1,FEE _- POOL 101.0004.21-000. 124,00
'Z"3. [X.. TR.ICAL FY3 -- POOL 101-000-420-000 �rt'l. tJfl
Plkt XIDT,t•IO PEE P0011 101-000-119.000
KID -TOTAL C0XdKTJC "101T AND PLAN CkM=
S363-30
1�:€ ai^ Pk I's0.00
f"Atm FEWW.F =5 D€7.F. NOW
10"
JUL rUu
M!
MYOF LAQUINTA
FINANCE DEPT
RECEIPT
DATE �"I
1
BY.p-� W _.
DATE FINALED
INSPECTOR
7 -
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
4
Final
Final +
POOLS - SPAS
BLOCKWALL APPROVALS
steel
z -6
Set Backs
Electric Bond
FootingsMain
�t
Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING- APPROVALS
Gas
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral ti
Pool Cover
`Sewer Connection
Encapsulation
Gas Piping
Gas Test
-Appliances
Final
—
COMMENTS:
�s
.k
Final ,.
Utility Notice (Gas) s
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) -
E
3 cjwAq
CITY OF LA QUI
BUILDING & SAFETY [
APPROVEI
FOR CONSTRUCTI(
)ATF %% RV r**L
E
A RE -INSPECTION FEE OF $
WILL BE CHARGED IF THE APPRM
PLANS AND JOB CARD ARE NOT
THE SITE FOR A SCHEDUL
INSPECTION.
.NO EXCEPTIONS!
q t
2-1�\ ZA,,--U GT
7- 9�S ;
FIRE PIT AT +18" WITH
)OL UIPMENT.
STACK STONE SPILLWAY
18" END BOOM AND
AT +30"
RAISED BOND BOOM AT +12"
CONCRETE GAP.
WITH CONCRETE CAP.
STACK STONE SPILLWAY
BROOM FINISH COLORED CONCRE-
AT +18"
PEBBLE_FIN15H WITH
• DECKING , COLOR TO BE SELECTEI
QUARTZITE STONE WATERLINE.
36"
SUN DECK AT -14"
V X T RA15ED SPA AT +18" WITH
CONCRETE CAP AND QUARTZITE
WATER LINE.
P.B.
1�
•
P.B. 36..
POOL
35' S
O..
..
'. ..:'.
• - P.B. ...
...
D
G� L.
2-1�\ ZA,,--U GT
7- 9�S ;