9903-262 (RPL)LICENSED CONTRACTOR DECLARATION
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
04
W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
ti w f ' 536236 C53 02/2,R/201
Q i !
Z I-- ✓Date Signature of Contractor a '
Coo O_
J F- p OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ Q License Law for the following reason:
Z_ ( ) 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
t 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).
Cl) O I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
Z WORKER'S COMPENSATION DECLARATION
oCL
• 2'1 hereby affirm under penalty of perjury one of the following declarations:
r,�Cr
. O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W — compensation, as provided for by Section 3700 of, the Labor Code, for the
O Q performance of the work for which this permit is issued.
M Q () (y) I have and will maintain workers' compensation insurance, as required by
O L) Q Section 3700 of the Labor Code, for the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy.no. are:
Nt Z Carrier Policy No.
O FARNI;Et S' INS, CROL N2,01,`_ 7911.
g(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
3 subject to the workers' compensation provision�f ction 3700 of the Labor
Code, I -shall forthwith comply with those provlsi ns
,Date:. -� ^tel Applicant
W'
Warning: Failure to secure Workers' Compensation coverage s 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 orpursuant to
any, permit issued as a result of this applicaton agrees to, & shall, indemnify
i & 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 repfesentatives of this City to enter upon
the,above-mentioned property fo ins fiction purposes.
/Signature (Owner/Agent) 7 1 '� Date
BUILDING PERMIT PERMITN
DATEj/v VALUATIONLOT TRACT
JOB SITE '
ADDRESS '78-7115 H,ttl,'y`BERRY LANE
APN
_
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MIM
�1RINI;Iud? t"IrM IS
78J95 BAYBERRY LANE
44028 Ei,KHORN I'R.
1.AQUIN'.,A CA 92253
PALM GHSI?1U CA 92260
(mo)340.5521 C11](40 1604
USE OF PERMIT
NOP
P001. -ANI 0A
i"OOUSPA 01 LY, IN WL MRi&PLA'SMER h
POM AINVOR SPA. 14,200.00 LS
S:l,S'i'iNIA TED COST OF CONST ia13MI,ON
4,2ft."Ito
PERMIT Vf%SUNIMARY
PIAN CIMM ME 101-000-4:49-318 S 105.3t)
i;ONSTRYIC11:0N3=OM 10J0W4t8-0W $16^.00
XMC'I.MNICAL P%M, -- POOL 101 -OW -11121-000 -14.00
fii.VICTMAL FEE -- POOL 101-000.41 20-400 $,15A)
PLUMBING VEX -- K)0Bcil-(1U0-�1I3 �w7.lhl
SUB-TMAL C, ONF'i'RUC.;TION A D PLAN CSI CK
$363.30
I..tSS PRE -PI IO a SES
WWI
TOTAL PFI.�imff KES oull" Now
�,$Fi3.31D
RECEIPT
DATE
BY '
DATE FINALED
INSPECTOR
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
POOLSi - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I I
Gas Piping '.
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
A1,1.4'
Appliances
Final
COMMENTS: 6,3
r�`�iZ!�� 1 40 �J
�G�l
4
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)