0211-162 (RPL)t+;r
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
74.3118 B C11 A.JC to e,""� Signature of Contractor�
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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.
(,) I have and will maintain workers' compensation insurance, as required by
Seltion 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 `iTATf... ONE) Policy No. IS08"15•99
(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, ( Ind agree it if I should become
subject to the workers' compensation pro'�,sion i�pf S ction 3700 of the Labor
Code,.l shall forthwith comply wit �ose prrovision .
Dater �* Applicant -111v 1 r.+
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
fora permit subject to the conditions and restrictions set forth on : his
application. K
1:. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursua
any permit issued as a result of this applicaton agrees to, & shall, Inde I I My
& hold harmless the City of La Quinta, its officers, agents and employ s
2. Any permit issued as a result of this application becomes null and v J f
work is not commenced within 180 days from date of issuance of, s h
permit, or cessation of work for 180 days will subject permit to cancella on.
I certify that I have read this application and state that the above informatit is
correct. I agree to comply with all City, and State laws relating to the buil in
construction, and hereby But 1 representatives of this City to enter upon
the above-mentioned property, for purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
_
DATE /� / V&,%TI*��oC�� LOT TRACT
JOB SITE
ADDRESS M-385 �!.-1t11.1 )A RAMM1 C.
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
MOUN CAPUT COVE DEVE opmwr
3wil k:NIMI 113xSYX
P10. BOX 35,78
45-260 PAIWK...
PAl, M DEMWr C.A. 92211
IC) 92201
(750)347.0500 C 1.4 4998
USE OF PERMIT
POOL AND/OR SPA
POOIJSPA..ALARA15/BARR11E4<S SHALL BE IN PLACE, AT PRE-FLAS;P,Wt
.MSP9G'I'PY9. E@U11'fvf WT PA1C'.•.Cs51JRF HOT MC).f.fDl;D
POOL, XKWOR SPA i ifgo, D0 LAS
71M MAUD C O&T Cali C-01PTnKiDMON
12rom0o
PL,!ll,i 0:1fEt,11C FU107.000-439.318 017175
COF .TrRUCI"IA.31d FEE 101-000.41$1-4 00 51.33.00
MWH"ICAT. DTKL -- POOL 101.0900-421-0900 M09
.
ELECTRICAL PFL; »- POOL 101-000-42M-000 $45.00
PLUMBING €+8F •- POOL 101.000-419-000 527.00
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NOV 2 2ti°•,�
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CITY OF LA Qi14I.4Y A
FINANCE DEPT.
RECEIPT
DATE S
'BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
S
4
I
Final
;
Final
POOLS - SPAS
P
- BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
_
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Final
Underground Plbg. Test
Gas Piping
f _
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
!
Water Piping
Plumbing Final
Pi�mbing Top Out
Equipment Enclosure
St.mer Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Setjer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
final
..Wtility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
s Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
i
4
G.F.I.
I
Smoke Detectors
Temp. Use of Power
I
Final
Utility Notice (Perm)
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