0104-027 (RPL)LICENSED CONTRACTOR DECLARATION PERMIT#
W I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT 0104-027 TRACT
til CO Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date Ei'1.28.fX) 14M JOB SITE - UN
APN
6- l ` �•:.rW M ,( t+{!r iP a ADDRESS
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cZ ti ,Date r ',�" �, Signature of Contractor 1 s. ✓ �� OWNER CONTRACTOR /DESIGNER / EN INEER
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J U w OWNER -BUILDER DECLARATION L��h3"t€rzy maw A , Cowwastrog CALlF0.4WMR00 ;!► SPAS (TOP .i' MN
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a I hereby affirm under penalty of perjury that I am exempt from the Contractor's i 135 so, V > w*, S:C.L. a2w 74725 AMIDRNH, S.LET;E RA
U) License Law for the following reason: SAN ] I.1s3'AI�''L1W0°' CA '�r^� 08 P1�,�i.1'IA `,C)•F��1IRT CA 92,,x60
Z_ ( ) I, as owner of the property, or my employees with wages as their sole �C 40n9WO (MY.B .35,E
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals P0 O , AXWOR SPA
Code):
( ) I am exempt under Section B&P.C. `or this reason "3Y3-t3.XA;139 N PLACE,' AT PR&PtASTu.
O N Date Signature of Owner t't�'SPIU'�tON. 91.1`; OFF' `r{IOH OL"K WALL. CITY STA.�f�J�,RA
drn
Q WORKER'S COMPENSATION DECLARATION
QQ 1 hereby affirm under penalty of perjury one of the following declarations:
F- 0 O 1 have and will maintain a certificate of consent to self -insure for workers' POOL AAWOR SPA °' ��y�{1�,00 143
X W compensation, as provided for by Section 3700 of the Labor Code, for the'{'•'J�;,1,1, tS.tI411.�r
Ori J Q performance of the work for which this permit is issued.
QU (��,, ) I have and will maintain workers' compensation insurance, as required by
O U 4?i 3700 of the Labor Code, for the performance of the work for which this
d ti permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No..
ob d SITATE C01AP:.@dSATI 0460610A 3� ISVI!! '.;`KED COST OF rCDuglt°at',rl^.IRCA.IW °f!li��l.�a3.et6J
g (This section need not be completed if the permit valuation is for $100.00 or less). MRW RUMMARY
() I certify that in the performance of the work for which this permit is issued, PLAN C]i 'K FIT, 101 ^000"439"31 £f %140.40
I shall not employ any person in any manner so as to become subject to the C014VI'MUC'1IOM FEZ 101-000-41 8-000 $216.60
workers' compensation laws of California, and agree that if I should become M'KCHoAl1i£ MPIM, •- P 0 0 L 101.4(30,411^COLI $24,00
subject to the workers' compensation provisions of Section 3700 of the Labor it ECTRICAL, FfU!, - POCIA, 101-,1300:,e120-000 $45. L10
/ Code, I shah forthwith comply with t os`e provesions,
D te: /' Applicant !'f�CID!('ra11 ; c -• 't3f;11, 101-000-419-000 $27.00
'10 Warning: Failure to secure Workers' Compens4t on 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 Mill WI"AT, COMMUC, 1.104 AND PIANffl, G S452.40
any permit issued as a result of this applicaton agrees to, & shall, indemnify - LOS ` ".'_PADM4 Q10,00
& 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 I''3 Y]C�I3K NOW ��
work is not commenced within 180 clays 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 or inspection purposes.
RECEIPT DATE BY DAyE FIL�D INSPECTOR
Signature (Owner/Agent) �� h Date (j;' �' aw ���
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
Set Backs _ _
Footings s is jd 6
Bond Beam _
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
i
fY
_
Final( 'gg
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
_
'
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
O.K. for Finish Plaster
Pool Cover
Encapsulation
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
��a�
Fin
Utilit 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 (Penn)