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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. "I
License # Lic. Class Exp. Date
14'r5612$ C53 t1SC i tilt2t
DateJ2_21 2• = Signature of Contractor z�zaii 44e
P.
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.
J )�I'have and will maintain workers' compensation insurance, as required by
Sec ion 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 SI A',13. EC0)'<01"_W9AT1 Policy No. 046-6102,200.3
(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 pr visions of Section 3700 of the Labor
Code, I shall forthwith comply with thos�6 rovisions?
Date: Applicant (" J;,,,1
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 or Inspection purposes.
Signature (Owner/Agent) A �`' �`��. Date 112 - 2210
BUILDING PERMIT PERMITk- .. .
DATE ,•, --� VALUATION ��•�`�� LOT 06312-1.97 TRACT
JOB -SITE
ADDRESS.�1���!
APN
_
OWNER
CONTRACTOR/DESIGNER/EN (NEER
IWOVA' II.' RESORT CONN3LIM-IM-:5, ,'9'C..
CAT.,iMMA.IOOLS tk WAS (TOf, MAW C01
200 :E, WA%1 UN(Vi*Q4 AW:. # 1100 .
86•1.010 AVENUE 54
"CONIIDO CA 92025
COl Cr'b/��]92Z.36/�}�✓}j�
gY(EpY.[3]19.jA�
(760)39&9222 03L# 0035.
USE OF PERMIT -
POOLAI,WfOP. SPA
,POIDUSPA; ORQW42 Z31.S&1995] FIREPIT'I(496ACIALN
AI ARMSMARIERS SHALL BE TH PLACE AT PIU-.PUSTER 1145PL�
EQUIPMENT ZNIC:i.Ei:�Lrl2E NOT INCiC ii:i3lW
S.S.
Cc 23 203
POOLANDIOR. S A 1&U4L+yG0
/usyC� t'rdcr'y:
mumA,TED corr ov C'o1.'a';ti"TRuC'T:L'O T
�,W►Ot1j010
PLAN CHECK, FEE 19�Af�07-R3��1� 512%.n�
CONE°TRUCT ION PEE 301-000-418-000
M1;(1H"ICA.L ":E -- FOOL 101.000.427. -000 $24,00
ZLECTRIOAL F17,- POOL. 101-000-420-000 $45,01)PI.'L1MB111943
FIE - POOL 101!-000-419-0W $27:00
=340TAL CCI��TCnC X AND PLAN C I C
$4.07.85
I= 'PRIM-11AUD I -MRS •
$0.00
..
-Eq-CAL Pm , ' s ]DUE .t.'!'V !Y '
WMS
RECEIPT
DATE' ��
BY !
DATE FINALED
INSPECTOR
k� �
i
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
POOLS - SP
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond -�
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test 117
Final
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
Appliances
Final
Final
COMMENTS:
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures .
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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CONSTRUCT)ON OFFICE PHONE NO.
SCALE -DATE 6RAVM BY I S(XD By CHQW�
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MASONRY
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DRRYNI4C.E NOTE-
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