0008-257 (RPL)LICENSED CONTRACTOR DECLARATION
I herebyaffirm, 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
% i �8, / B TIAZ 1 /2(
•Date ` ¢'' 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).`. V,
( ) 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 Policy No.
FITATE FUND ' 229-00 UNIT 0004483
(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 kny person in any manner so as to become subject to the
workers' compensation laws of California;, nd agree that if I should become
subject,to the workers' compensation=revisions of Section 3700 of the Labor
Code'l shall forth ith comply w51rhose provisions.
afe '�f of Applica&''� 6L/ Z 11"*'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminalpenaltles and civil fines up to $100,000, in
addition to the cost of compensation ,;amages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Appy atio�hereby made to the Director of Building and Safety
for aipermit,subject to the conditions and restrictions set forth on his
a 0rication.
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�forrin pectio• nn purposes.
Sj • nature (Owner/;4geDate
BUILDING PERMIT PERMIT#
DATE �' VALUATION LOT 0"_2S'7 TRACT
JOB SITE t
APN
ADDRESS
I.3 -ice AV'.�N1DA R'EM10
_
OWNER
CONTRACTOR / DESIGNER / EN (NEER
STARL ORT 1 AC�}k%P_XT WC
WILLTAM RLfSS)rj L R013M
51-370 AVY"A B}M1t P3,
56900 JAMON S'T
LA QL,IIN=CA CA 92253
1�"'C�. AAL CA 92274
(760)399.1200 C'BL# 1954
.r
USE OF PERMIT
TOOL ANDIOR SPA
POOL ONLY NO I3FATER, - ALA t1aI MA.RRIERS ;11.1.ALL 8E IN PLACE AX
PR&PL.A:iT R INSPECTION, POOL EQUIPMENT .ENCLOSURE NO,
INCLLII&D IN THIS PERIBIT.
POOL ANDIOR SPA 5,0moo W1,
c
T18TMA131) COW OF Cl NYME 7CT OM
$,930t)w
PLAN CI°IF? K FEE . ] 01.000•'439.318
CONS!'R.t1CTION FF 101-0t3C1 1£t-t10fl $99.00
ELECTRICAL FEE -- POOL. 101-000-420-000 $45.00
PLUMBINO FX9 •• POOL 101-0004M000 $27.00
'A
SM=:i`O`FAL C014M1RUC.ROM AND PLAW CiWICK.
$2,15.35
'� F-.�8 PRE.P.41D MS
$0.00
u;
11 %%
RECEIPT
DA E ]�
By�
DATE FINALED r
INSPECTOR
vV
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs L. -
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade I°
Return Air
Steel 1,
Combustion Air
Roof Deck 1
Exhaust Fans
O.K. to Wrap la
F.A.U.
Framing ;'.
Compressor
Insulation
Vents
Fireplace P.L. ,,
Grills
Fireplace T.O. 4
Fans & Controls
Party Wall insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath I:
11
1L
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam It
Approval to Cover
Id
Equipment Location
p
Underground Electric
I
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
1!
Gas Test
Electric Final
Waste Lines b
Heater Final
Water Piping I!
Plumbing Final
Plumbing Top Out I?
Equipment Enclosure
Shower Pans ld
O.K. for Finish Plaster
Sewer Lateral II
Pool Cover
Sewer Connection 1,
Encapsulation
Gas Piping lu
Gas Test
Appliances I'
It
Final
13
Final }r
Utility Notice (Gas)I+
ELECTRICAL APPROVALS
]f
Temp. Power Pole I6
Underground Conduit
Rough Wiring 1i
Low Voltage Wiring
Fixtures 1C
Main Service 11
Sub Panels }1
Exterior Receptacles
G.F.I. I!
Smoke Detectors 1.
Temp. Use of Powe-
Ii
I}
Final rf
Utility Notice (Perm)
COMMENTS: