0008-319 (RPL)- LICENSED CONTRACTOR DECLARATION
U) I hF„�eby- Zirm under penalty of perjury that I am licensed under provisions of
H Cri'lapter �'commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
p Z) ch License # / Lic. Class Exp. Date
~o Z r- Date Signature of Contractor
CD 0
J U C) OWNER -BUILDER DECLA' N
LU w I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ Cn License Law for the following reason:
Z_r ( ) 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
N Date Signature of Owner
ON
Q)
Q WORKER'S COMPENSATION DECLARATION
o< hIr I hereby affirm under penalty of perjury one of the following declarations:
LO -- O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X LIJ �= compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
tiLOH permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
cb m a�Ttz 1=U 1� 10614$7-Q�
O
J (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
3 subject to Pe workers' compensatigo-provisions of Section 3700 of the Labor
Cot V ith comply with those provisions-
Date: Applicant' -
11111111 Warning: Failure to secure Workers' Compe 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
4 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 far ininspection p rposes.j7
Signature (Owner/
,gen
t~c f'%.�.'.•'' Date
BUILDING PERMIT PERMIT#
DATE' ��VALUATION LOT `�19 TRACT
slammoo
JOB SITE
ADDRESS.
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
A1r )M SMdk'k°Z+ M
DATE P JIM h- r ERNIMS
55-4722YRAS. ITRN
R1..9651'►+IOUMPffl'iMW?. %:
LA QTTIEA4'3'A CA -32253
LA QT_TW A CA 92253
(760)391=5300 MR 18"
USE OF PERMIT
POOL ,11N� /0111, 8PA
POOL & SPA ONLY-ALARNISMARRIIERS SHALL HE IN P1ACE AT PRE
PLASTER I14SPEC:TION.POOL EQUIPMENT ENCLOSURE IS NOT .fr7CLUDRI)
M THIS PE10AIT
POOL ddb I OR SPA. W
ESM"TED COQ' OF C0NS7TVVCnCW
191000J00
F.M. UT FEE 910TUMARY
PLJ`1.1a CHECK FEE 101.000.439-318 5122105
CONSTRUCTION PEE 101-000.418-000 W0,06
T
MItLRKMIC,A.L I±EY, POOL 101-000.421.000 $24.00
h i
ETYXTRiCAL FEE - POOL 101-000-420-000 $415,00
ibL1SMPIN •02 E -• POOL 101.000.414.000 $27.00
r
Y�•� Ty�1 �
Y4�
.3"M
8XJ,BA` AL 0,1014=11=1014 AM K" CM- Car
$407.83
PRE -PAID P'1
$0.00
fqrAL rommyns vu now
W7.65
RECEIPT
DATE
BY
DA
INSPECTOR
1 L O
Com'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
1. 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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
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
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)