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LICENSED CONTRACTOR DECLARATION j
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 DATE
Professionals Code, and my License is in'full force and effect.
License # Lic. Class' f ;:-EDate
Date 4�9�rr�45
Signature of Cdnt�ac
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, 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).
( ) 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
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:
Cartier INS, COMPANY Y OFT Policy No. iWDF 1,70041900:
(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,asto be me subject to the
workers' compensation laws of Californi nand agree�a if I should become
subjeef to the workerscompensati �n+plovlslons of�Section 3700 of the Labor
C� de, I/shall forth.wi comply w�ath'tho� provis drys.
k3ate: Applica2_ 11/
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.
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 dayswill subject permit to cancellation.
I Certify that I have read this application and -state th�the above information is
correct. I agree to comply -with all City nd State laws relating to the building
constr ction, and hereby autho� epresentatives of this City to enter upon
th ove-mentioned prop *f 'Inspectio 15'urposes.
j BUILDING PERMIT
VALUATION LOT
JOB SITE
ADDRESS 78.9XJfta5MINGE TY.ft
OWNER
RST' MVESTMM Ti' , DTC.
14.25 & 'UNIVL'RSrIff DRIVE
RRGiEAt;,l: AZ 55034
USE OF PERMIT
POOL 113�0fOA LIPA,
PERMIT#
W6-017 TRACT
49
APN _
CONTRACTOR/DESIGNER/EN (NEER
14.25M UN1V0ZM7ffDR1WJ
PROEM AZ E€5034
(§02)257.1656 CBIX. 4990
POOL &SPA ONLY. ALAW iWARIZIERS SHALL 8L IN PLA -I! AT
PRrt',P6,%8T9R INSPWT014. AWCK WALL P0.I1. EQUiP1AiKN'T ENC:i SIA
13 NOT INCLUDED rN THIS PFAMIT
VALUATION
1keoo: a I's
F:S'1i qw) cosr OF C10.iJ9MOC.i. oR
PRUNUT Fn gum -WARY
PLAN CHECK FEE 101 �000c439-318
CONSTRUCTION ,FM to1-000.116-000
MIECHATICAL FUE •- FOOL. 101.000-421.000 S24X0
ELECTRICAL L�I�E - POOL 101.000.420-000 $45.00
PLUMBING FI.s� -_ POOLS 101.000*419.000 9".00
M40 RRX-PAED FJW&V
i`C r >'M"W Ims P Now
RECEIPT DATE BYA DATE FINALED INSPECTOR
1010W.00
I'i�% .•
<� r
'* t�
$269.05
SO -00
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
POOLS - SPAS
Set Backs
Electric Bond—����
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
8
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
- GU
Gas Piping
Gas Test
Appliances
Final
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:
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE � -6ro. BY 4Z:�_
ON
RE'
FEE OF 134
INSPECStON
VaLI BE CHRRGED IF p ARE NOT a
twin AND
AA SCNEDULO
JHE S
ViSPEC10-
.NO EXCEPTIONS!
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