0201-057 (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 # Lic. Class Exp. Date
595,54 X31 C.9
Date Signature of Contractor ( t�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I amexempt 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 Sianature 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 STATE FUD Policy No. 229.02UNIT 0011091)
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance df 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 comply with those p ovisions.
Date: L- I A- Q 7 Applicant � �_ 211• a�
Warning: Failure to secure Workers' C zm pensation 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, inspection purposes.
Signature (Owner/Agent) �{ rfi, e /f Date —1— 14
BUILDING PERMIT PERMIT#
DATE%� VALUATION LOT 0101-057 TRACT
E=/
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% ��I�C. ^' "-gym^-..n' �.J�+►} ` -_."-'u.0
JOB SITE
ADDRESS ,,,�ZA,�r�I���.f%�Xt,�I��
APN
a ••
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WOML CARRLL3. O
PA71 CONSTRUCTION 00
1A C VI lA CA. 92253
I.A rZWrt% CA 9225:3
lk'
(760)564-302.3 ( li3 5537
USE OF PERMIT
POOL AMWOR OPP.
PC3OI ISPA..FidoNRM /0Alr.liI9R SHALL BE IN PLACE A I PIPI-PLAS'6'V
I14ISPKCTION, POOL 9QU9P:lo✓ M- ' R'?d:B.C'rSi31. F XOT Ii'ICL.tll) A
PC*L..AMOK SPA 9,0W.09 1.9
XKMAM (70, OF CfiO.%1UMUC:'TtON
�,I3fit�Do1�
Mmn'FFM SUMMARY
PLAN CI'jliCK. VEr, 101.000-4,39.318 570.20
CONSTRUCTION KE 101-000-416-000 $.103.00
A#MIANICAL FEE -- POOL, 101.000.421-ou'o r^ $24.00
rg,;ii`,:TRICAL. YZ_M;,• POOL 101-Ot'10.620-620 $45.00
1•'LUMDIx+ FEE --`P001, 101.000.4194,00 S2'iAD
�' t1
JAN 14 2W
-of LA
MI., -TCnTNI. _.... .. KANDPIAN rG,K
$274.140
LWY. "_,PA(D Fr.XS
$0,011)
TOT',AIG rKffi T'J. � .8 DWY .1 OW
$2,7420
RECEIPT
DATE jl
BY��
DA FINALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I t
Underground Ducts
Forms & Footings I i
Ducts
Slab Grade I!
Return Air _
Steel (l
Combustion Air
Roof Deck I (
Exhaust Fans
O.K. to Wrap I i
F.A.U.
Framing I1
Compressor
Insulation (.I
Vents
Fireplace P.L. I I
Grills
Fireplace T.O. I (
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall I I
Exterior Lath I I "
Drywall - Int. Lath 1 i
I I
I I
I ]
Final
Final . Il
POOLS - AS
BLOCKWALL APPROVALS
steel
Set Backs I I
Electric Bond
Footings I (
Main Drain
Bond Beam it
Approval to Cover
!
Equipment Location
I ]
] I
Final ] i
Underground Electric
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
i,
Gas Test
Electric Final
Waste Lines I l
Heater Final
-Water Piping I I
Plumbing Final
Plumbing Top Out I I
Equipment Enclosure
Shower Pans I (
O.K. for Finish Plaster
Sewer Lateral I t
Pool Cover
Sewer Connection I I
Encapsulation
Gas'Riping I
Gas Test I i
Appliances ] l
J {
11
Final
COMMENTS:
a/� /-
]t
1(
FirW 1I
Utilly Notice (Gas) I
6> ELECTRICAL APPROVALS
Temp. Power Pole; l
Underground Conduit
Rough Wiring I I
Lbw Voltage Wiring'
Fixtures II
Main Service ] I
Sub Panels ] 1
Exterior Receptacles
G.F.I. 1I
Smoke Detectors I I
Temp. Use of Power
II
Final ! t
Utility Notice (Perm)