0203-123 (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='
...............
Daterf�%� Signature of Contractor j;'
' 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.
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.
STATE TE F'f.}ND 134402-01
(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•fonhich this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of C,Ja ifo a, and agree that if I should become
subject to the workers' compensation, -provisions of Section 3700 of the Labor
��..,
Code, V. s �AIMoV. f hwith comply with tho e,previsions.
Date: e , Applicant
Warning:`+Failure to secure Workers' Cofinpensatlon 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 withiall City, and State laws relating to the building
construction, and hereby aut olri2e representatives of this City to enter upon
the above-mentioned property'f6r inspection purposes.
Signature (Owner/Agent) i ~ t}�X-" �! Date"
PERMIT #
B U I L D INi. G'`RERMIT
DATE VALUATION LOT TRACT
-. wpm
JOB SITE
APN;-.
ADDRESS 314.140 ANWIDA RAIMM.
-
OWNER
CONTRAC6TOR/DESIGNER ENGINEER
ryJi
AMSGSOOUI-JNIT,yc51_14
51241 9 A'+IWIDA RAMMFZ
53300 AVM41DA,1:AWBXrEZ
LA.QUMT...CA CA 92253
I..ACIUIWT.A CA ` 2253
(760)564-3655 CIBL4 2893
'
USE OF PERMIT
T'001, AND/010. SPA
POOL AND SPA ONLY. ALAP..2Jtu,'SAPJ2lERS SHALL BE Rd PLACE
TO PREPL AST ER JINSPEXT16M POOL EQUIPNIZ rp :n NC'[.Ot3URV. 40T
INCLUDED IN P;v,R. XIT,
Pool, ANDIOA SPA: _ 16,000,00 LS
EMMM COST OF C°o"TR rCTION
PERAW DWI 9UADAA.RY
PLAN CHECK "X1 $111.15
CC)NISTRUCTION Fly
M&C HANIC°•AL FRE -- POOL 1011 -000 -421 -POO :GO
F_LXP.TRIC"ALPSIC—NOOK'., 101-1100-420-000
PILUTA4.B1NO FEE: • POOL 101.000.419.01M WIWI
�� • t C�?1�:STREJL"liC�l~iI PLAN
v\ ? EW P Fs -F FF'
5 $0. UQ
V%1 ,?•'E3E0MFEE1 DUE NOW
L
RECEIP
DATE
BY _
DATTYFINAL
INSP�
a
icy,:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
,p
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas rest
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
,,Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
v
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Puretic Equipment
1 hp Whbpwfb Pump (circ.
1.$ hp Whhgwfb :Pump. 0 t2
420 dm. filter
2$0.000 btu ' MWffw Hedw
00
O
00 nr..
El
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51-240 Avenida Ramirez
LA QUINTA
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Construction
Pools Spas Fountains
(760)564-3655
Lic. #658996