9907-605 (RPL)„j .
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch;,',*1er 9 (commencing with Section 7000) of Division 3 of the Business and
ProiNionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
-OP
,6561'28 c5i
Date 7/ 2 -7 /1 � Signature of Contractor—
OWNER-BUILDER DECLARATION.
I hereby affirm under penalty of perjury that I aFTI oxer-ript from the Contractor's
License Law for the following reason:
( ) 1, 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).
1, 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 require d by
Section 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.:
Carder Policy No.'
STATS F UND 168
(This section need n ' ot 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 agre th t if I h
f �e ctai I knp ould become
,o
subject to the workers' compensation provisions o - e -7 0 of the Labor
Code, I shall, fort With comply with those provisiogs
Date: ;1/ 1i Applicant ._f�_ _0
Warning: Failure to secure Werfe_rs� Compen . sation 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 applic ' ation becomes null and void if
work is not commenced within 180 days from' date of issua ' nce 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 buildin�
construction, and hereby authorize rep resentativE�� this City to enter up
S
the above-mentioned property for inspection uroses..
r/Agent)
Signature (Owne Date 7/0/f f
BUILDING PERMIT PERMIT #
DATE VALUATION LOT TRACT
OW/1” $19po"me
JOB SITE
APN
ADDRESS
55-6is ARM', BURN
OWNER
CONTRACTOR / DESIGNER ENGINEER
BROOKFIELD 110NIESSAINT D11,M, DIC',
&SMS
12963 POWIT, DEL MAR, SUrfE.100
74-725 JONI DRIVE, #A,
UE'L. futAk CA. 92014-309
PAUM DESERX CA 92260
V140iWA 3-55
USE OF PERMIT
P0011 AWIVOR SPA
POOL & SPA.&MG WATU4, i%"XIME
bh PLA.Q; AT 71ME 031,' PX&PLA811N, i
POOL AN11'01Z SPA. T.S
CISTIMA' MICOV11 OF C"Oftf
PERMIT VVIE SUMMARV
KAN CfIRX SYA.55
CONSTRI"TION $207.0
MECTAXIC.Al. FUM -- POOL 10.1-000-1121-000
MCCTRICAL 1THE — POOL'. 1014*�120440
PLUW31NO FEE P00L .1014)00419 -WO S27.00
_SUB-T(.yrA LCON9FRUCTONAND PIL.AN C-34ECK
$4375r,
LESS P&E-PAIDIFEES
$0.00
TOTAUI PERMIT FKC-40141-Now
RECEIPT
DATE
BY
DATE FJNALFD
INSPECTOR
.
I .
I t6 /X?i ) cl I
I I
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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 & Controls
Partv Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond W
Footings
Main Drain 7
Bond Beam
Approval to Cover
Equipment Location
Underground Electric 1_4 —
Underground PIbg. 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
COMMENTS:
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)