9907-591 (RPL)Ll('FNSED CONTRACTOR DECLARATION
i hereby , affirm Und';i71�enalty of perjury that I am licensed under provisions of
Chapter 9 (commendin`6'6th Section 7000) of Division 3 of the Business and
Professionals Code, and my License i� in full force and effect.
License # Lic. Class Exp. Date
636129 C53
Date Signature of Contractor
01
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contracto�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).
am exempt under Section _, B&P.C. for this reason
Date Signature of Owner
WORKER'S COMOENSATION 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 caerier & policy no. dre:
Carrier Policy No.
(This section need not be completed if the permit valuation ' is i 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 !01 ould become
subject to the workers' compensation provisions of SectigpdV00 of the Eabor
Code, I shall forthwith comply with those provisions
Date: 2 1 ip 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, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTA ' NT Application. is hereby made to the Director of Building and Safety
for a permit subject to the conditions, and restrictions set. forthlon 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 pyrsuant 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 a's 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 representativ slo-Fthis City to enter upon
the above-mentioned property for inspection purpo es.
Date
Sionature (Owner/Anentl
BUILDING
-PERMIT#
PERMIT
9907-59i
DATE VALUATION
swwoxe LOT TRACT
JOB
ADD9�!�S 55-495 BRAR BURN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
11.1f,"MKIFIEU.) 410f,"EiS SAN
D, -ftk�
`0 10"1 SPAS
CAL11' 1JA_?0,Vv
12865 FOINIVIX-'L MAR, SUM' 200
74425 j0N I DRIVE, �fi A
DEL MAR
C'A T2014-3469
MUM OESERI' CA V22,60
USE OF PERMIT
PWL JU4DJCA 'SPA
SPA 41ALL EABN FLAC8 AT T WE OF
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X I&I 1K
1% R�411'VVF, SUNINI&RKY
PLAN CMEXX i,Eili
H.).1 411()11-41940) 1 f�l
MECITA-NICALF138 -- '1001,
A.
1.0.1-M-4111-000
ElIX14:31(tchil
P1110WINO FEE - - P00L
WI -00-41440)
CONSTRUCMaN AND P1,AN CWCK
$221) 6's
I S
70]'M, PERAIFF "MN VUE'N(M
1>)YJ
RECEIPT
I
DATE
I
BY
D TEfINALJD
(
I INSPECTOR
q
10*
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. 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
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric 1A
Underground Plbg. Test /M/V,
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
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)