0110-164 (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
Date Signature of.Contractori
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).
( ) 1, 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.
( ) 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:
CartierN�a,'r MAD Policy No. ;;�2Ski1-0
(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 Se3700 of the Labor
Code, I shall forthwith comply with those provisions. /7
Date: Applicant V 1f
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to1$100,000, in
addition to the cost of compensation, damages as provided for in:Sectiori 3706
of the Labor Code, interest and attorney's fees. +'
'IMPORTANT Application is hereby made to the Director of Building and Safety
for i 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 perrnit 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 herebyti authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes..
Signature (Owner/Agent) l �~ T-
Date •�
.. ', BUILDING: PERMIT PERMIIT#c
- 164
DATE VALUATION
�,�� �'�i,t99 1��11 LOT TRACT' '
$60Y00)
$ 6 ,Taia�d)
JOB SITE
°�
ADDRESS „!'y'i�lf"ARifu
APN
r
OWNER ,
CONTRACTOR/DESIGNER/EN (NEER
C"O•�?�.�7d3�tf4�:F3wwC:•�+i"£"ttikg;�
P10. t�L/.1.•. -9
aLy�'4fAjF1@nCfdf�.�C�:±~95��tit'v��p�i(e�774�^"��Clnfai�kywiWt�yvt ��
/ei`3JN .�'in`8tl..eAmi." �S Y'N.bl�a"A4iV eFG/S•7,.nX!aL,SQ
LA Q'U7k+i'. A CA, 92253
.:i A QTJ-. NT.A CA. 92233
l"Y60)5&4-4fr MR* 22,61
USE OF PERMIT
P0OL fi. TDOR. SPA
PQ Jt./aP,k1,, A,�.il.l� '�,.+`11Jd .YXUfl a SHALL F36 uN PLACE AT 1PRE-PIASTER
NOW77014. POOL EQUtPMZNT RNC" A)SURE NOT INC?,C. M.
POCaL.RsAfWOR SPA Qyt��U.t10 Lei
WffNA 0 C4 &-f OF CO��4�' �MMON
6,M)MID
.P.,"Xr nxx s'um'Any
PLAN CHECK FEE' 101-000-439.318 $5165
t;ON.TfIC.UC`!`tfaNFEZ 101 -OM -419-000 $91.00
MECHANICAL ME -„ POOL -1e 011mC00-42jp1�-000 $24,00
an: P.LVr/ .'L J�.sCX., .VEY. -d F L -'101-000-420-000
01-03.Kf•'420—Ai00
MiTMMO RIF, P06101.00O-419. wOCI) 's i'ARA
f
k, OC f 3 2001
CffV0FLA QU1NyA
PIMAN
t3 M i'O 'A . C}k'1 ' `T �'.
$229.o
,. MOS. ®XZX4s^� PWD FEES
$0.00
,At
•�:e`.tI.YEAl:ix-RRM'Ai'1�n'J1;RXT.R(51NOTi
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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
BLOCKWALL APPROVALS
Set Backs
1POOLS-SPAS
steel
Electric Bond
I
Footings
Main Drainq..0
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
.Final
Gas Piping
_Q
PLUMBING APPROVALS
Gas Test
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'
/
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fudures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
!!!