9907-593 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
ChapteU4wp4kencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class 'Exp. Date 110e
656128 C53
L2)1qJ
Date 7 Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt 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 required 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.;
Carrier Policy No.
STAIVIMND
(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 sbg.uldbecome
subject to the workers' compensation provisions of Secti 3765 of the Labor
Code, I shall forthwith comply with those provipAs,_,�_111_
Date: 7 1232"15 Applicant 6—
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 at 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 Iiis
application.
1 . Each person upon whose behalf this application is made & each person at
w �ose request and for whose benefit wor . k is performed' under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnif�
& hold harmless the City of La Quinta, its officers, agents*and employees.
2. Any permit issued as a result of this application becom.es'null and void.if
work is not commenced., within 180 days from date of issuance of such
permit, or cessation of w6�k for 180 days will subject permit to cancellation.
I certify that I have read this . applicationarid state that the above information is
correct. I agree to co�nply with all City, and State laws relating to the building
construction, and hereby authorize representatives Of this�City to enter upon
the above-mention4d property for inspection purp-o
Sig nature (Owner/Agent) Pate
PERMIT#
BUILDINGPERMIT
I
IOA111140.)
DATE IVAILUATION LOT TRACT
JOB SITE
ADDRESS 5&647 8RA_K HURN
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
BROOKFIELD HOMES S'AIN I X E 0 0 1' N, C,
CAlAt"ORN11A P(X)US &SPAS
12865 P01WE DEL MAR, SUrr.E 200
T 4-725 ION I MOVE, #A
0E I. M. A K CA� 92014-385,�
PAL&I DESERT CA 92260
(InU4 351
USE OF PERMIT
110CA, AN'DiOf( 4
SP.A.0MV. Y.%LARIMSiBARRIERS ;4 4,411, BE IN 0L Cli AT Tac OF
POOL M4TWOR SPA Ls
EN 111JAIT"141,1D COST or COINIST I Ult �7101-111
IRV
QDNIMAX0
XIERMI.T F RE SVMJ%'AXV
PLAN Cid-XX FEE 9' S 52. 6 5
r�* C. �t q '.' , T R Yj(.,' F ! 0'-N" FT_ F 111) 1410041 84W IM30)
N,1!7U1AX41C'AL ME -- P0O*L 1101-0W,44`1 W0 $noo
KUNWIN.0 FFF', — P0QL 10 1 -000-41 V-0)0 $27.00
SIM -TIM -AT, CO NISIRIURCTION AND PLAN CH'FCK
651
LESS ME-IJAWFUS
$0.00
TOTAL PERWT FIC&S KIE"NOW
$229.65
RECEIPT
.11
DATE
_,T
B'
I DATE FINA_Lf
1.1 la 722 .1
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
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
Partv Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel nlllfl
Set Backs
Electric Bond -If I rl"1'7 -_ ZZ7
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
I I
Underground Electric
Underground Plbg. Test
Final
2Es Ei pii :ng
PLUMBING APPROVALS
-7
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: 7
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
UU14 Notice (Perm)