0002-066 (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
Professionalp Code, and my License is in full force and effect.
License # — w , Lic. Class Exp. Date
c�S'I8 r i:53 10131iM
Date C'ti 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). »1_1
O I am exempt under Section B&P.C. for this -reason
Date 2�v Signature of Owner 'A <<f.
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 i.T,VI-jB.l iJt.'j? • Policy No: _ 046 -0r) -if, SM'. 9
(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' cornpensation*provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.'
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 compensatiori, 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,represeritatives of this City to enter upon
the above-mentioned property fo? 11r inspection purposes:, 1
Signature (Owner/Agent)"�� 1 �-�r �'
Date
PERMIT#
BUILDINGPERMIT u002-066DATE �� �.1 /l VALUATION S1 ,"-(1-0€P LOT TRACT
�--
JOB SITE 779-520 .i.x+I:+.e APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / ENGINEER
n,QVT.:1)11 "0L11C}AT,-• } I I"1 C Y t}?�i'19Rf7 i! Ufil'lf S C. 41) 1 C
.Ala.OJLw I\♦ ...;♦ .,l3AY•I A L,% %, A.i./; �aJ l.i l.: fl1! ..n vl,.�.+ M. fJi SY 5!
3 .E't RIC P.*1FiZMS71 400 74-7 3ON,1. DRIVE. #FA
iR_V1NN• CA 9261.4 PA1,Ai 1)8SI-, T CA. 92260
(7(,())Y4)-9000 CM# 335
USE OF PERMIT
KitX AiVWOR SPA
VRE_14 A3'ii at jN f',vC,"'S' ou
VALUATION* 1.11,950.00 i.S
3l A4'3';t4'I.ziTED COST 01' CQeN,�T_RLICTJONI
PERM k"f FEF SUMMARY
PIX9 CHECKFjX' 101-000-4.39-•:318 �j.Q5.30
of -mc 'tur(','?`jC)10 FPF. Pill-�t!KF-4ifT.tj!l�t �i1ti9ti41
'M1A VIIAN`IC �tttt ME POOL
1 011 0001 12 1 11:16 ¢^ea �rft1
t� LI:Tf✓ililtYlLll.Lr 4' S+a.`. -- i vl/`9. 4 v i •villJ-' iL� 1. �V V U
B' JIC;i;i eAL FE -- .kala oi-M-420-000 i5.t3t1
PLUMB1N01FFF,--P( J+1 101-000-419-000
81.t.RIM-A 1, CONS'1RUCTfON AND 1:11, AN ('HEVK 0
�0
T'O iii, i'ER11t;iIT FEF.,.S ME NOW X3163.;34)
RECEIPT i DATE
DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set flacks
Underground Ducts
Fomis'& Footings
Ducts
Slab Grade
Return Air
Stee---
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 Firew?ll
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel w
Set Backs
Electric Bond !/lJ
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric =L .
Underground Plbg. Test
Final
—
Gas Piping 12
PLUMBING APPROVALS
Gas Test - -e—
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 .C.✓
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: