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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
Licenstj CC,�,� Exp. Datetiez,". 28
Date Signature of Contractor
OWNER -BUILDER DECL:ARATIONfes,
I hereby affirm under penalty of perjury that I arex
em F"from the C�%ont�ractor's
License Law for,04 following reason: �'' "
( ) 1,'%aslowner of the property, or my e p yees 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
rk
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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is�issued.CMyworkers compensation insurance eIje�r1&c�policy no. are:
Litiayji; i Al h'/��fk LL
Cartier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( )Ice fy 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
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to;$100,000, iri
addition to the cost of compensation, damages as prouldedlfOr6'1-e ion�7._06`
of the Labor C e rif teret and attorney's fees. % ✓ `ff .•'
IMPORTANT ZA plication t` 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
.fila
BUILDING,. PERMIT PERMIT"
+A `*yPj 1 i
DATE � {� VALUATION LOT TRACT
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JOB SITE diLP` 554 , r. "1 11 rffi
APN - y
ADDRESS
OWNER
U11Rf)'liATMI RE90 t` r
CONTRACTOR/DESIGNER/EN (NEER
l';ALMDR.NMP013118 & sr --A -rOp MAW ca.
200 F, W.PAMM40TON I'wVR 0100
86.100 At VET. Th 54 n
Ca i". iiyC CA 92025
00AC IA CAL 422345
(760),398-9222 CB1,6 00355
USE OF PE MIT
11.s10.r�Aw/CR, sPA
> Q1' .•./3.'K1'J'SAA. R'tit) ANSI 1.515.1495. A,1.A V
USM.Iu:F'1fr"RS SHALL
JaP 1H PLACE P1110R tU PREPIAAXfBER fNS131 TION,.
POOLAD1'OR SPA 18,000,00 US
FSTBUMD COST OF COM17-1RVC'A.i0,K
P.is`:RAM BTT SUMMARY
PIT CI•FZCK FF:1Z 101.000-4,39.318 $122:85
COINSI 'RUCTION i:VIi 101.-000--41R-000 SIF9.00)
MECHANICAL FBI -• POOL 101-000-421.-000 $.24.40
E1.IT"IRICAL FRE - POOL 101-00,0420-000 - $45.00
PLUMBING F F2 -- POOL 101.100-419-000 $27.00
SUB-11rarpal COX811'ft'fTMt,1N AM PLAN C.et="
$4V1.85
L� .00PP •PAIDF-"iiR3
8 :d" YN-F :�?TC.i�+Lt T 73 s D17r NOW
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CITnpY07FAGI1 8 y
RECEIPT
DATE'
BY
DATJI LED
INSPECTOR
v
lei
T.
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Seam
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
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
o
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: