9908-016 (RPL)r. -_- _ •, a `�;.� � - .: t- .... n�
t
LICENSED CONTRACTOR DECLARATION
ere affirm affirm under penalty of perjury that 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
g91 'Im B r 9 �j 08/31 /201
V9
ti :".✓� .{. 1
vate �s%�+�� V Signature of Contractor—
ll,
OWNER -BUILDER DECLARATION,
I hereby affirm under penalty of perjury that I am exempt from the Co tractor's
License Law for the following reason:
(.) 1, as owner of the property, or my employees with wages as, heir sole.r
compensation, will do the work, and the structure is not intended orereii for
'-
sale (Sec. 7044, Business & Professionals Code).
( ). l,_•as owner of the. property, am exclusively contracting• wit licensed
contractors to construct the project (Sec._ 7044; Business & Pro essionals
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 37001
1of 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 t workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
�3Gf�S�•C Li�
(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 Section 3700 of the Labor
CIN
ode, I, shall forthwith comply with 'those,provlsions
Vrate: f .6rM Applicant-- , ' , 64',,-C.er`d� sa'
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. 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 for inspection purposes.
/Signature (Owner/Agent) Date l/ „ N,- 0
d
PERMIT #
RUILDING:PERMIT � �t 5
'x
DATE j VALUATIONLOT TRACT
ig
JOB
ADDRESS
APN
'
+ i
OWNER
CONTRACTOR DESIGNER ENGINEER
LA. `JDI A PARM!RS
0S.
WILLIAM :fieQISTi>R..QEA
N-370 A"V%tdl.DA 737::RMi.rDAS
56900 JACKSON ST,
4A QUINTA CA 92.253;
THERMAL ill. 92274
('ICf)1. ►-t �t10 > 'l L,9 )954
USE OF PERMIT
P(x:)L i''..f' 'Di At SPA
!
POOL VNL Y, -NC .Hi3r:TM a'ALARM-11"3AUMP. S 814ALL BE IN PLAAt- A
P#tGI+I Afff HR INS.PECTIION
POOL hai'+i[YCM SPA 7,00.00;.s
PLAN L 9+ 14& tol.-000-439-3E8 $Ss.soni
c :raS'r gfrPt :~►1�eta 1014130-A18-00 sm.M)
MILEC-iRICA-L FM - POOL 1II1-000.420-CA' $4.5-00
14A) tr40, FLA - IN)01; I c01 -000-=b l.Moo
,81, fly-Z+3T.M: COI` S'HI.Uf.•'°T'ION AND FLAN c°RECK
$220.50
LESS PRETAID FEES
r4
RECEIPT
DATE
BY'
I DATEiINALZD
INSPECT R J
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
I
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
r
t
Final
;
Final
BLOC KWALL'•APPROVALS
steel
POOLS -SPAS,'
Set Backs /
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
{
Underground Electric
Underground Plbg. Test
`Final
Gas Piping
{
PLUMBING APPROVALS
Gas Test
Electric Final
[
{
Waste Lines
Heater Final
[
Water Piping
Plumbing Final
f
Plumbing Top Out
Equipment Enclosure
;
Shower Pans
O.K. for Finish Plaster
{
Sewer Lateral
Pool Cover
i
Sewer Connection
Encapsulation
Gas Piping
{
Gas Test
{
Appliances
I
Final
- (r 7 i
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: