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LICENSED CONTRACTOR DECLARATION
I beret;/ 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
Professionals Code, and my License is in full force.and effect.
License # Lic. Class- j fEzp Date
690645 /B'mc A / ' 07MIPU
Date 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:
( ) 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 hbyffirm under penalty of perjury' one of the following declarations:
v` I have and will maintain a certificate of consent to self -insure for workers'
r/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 OF T Policy No. '+ DE170041900
(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 iin.any manner so as to become subject to the
workers' compensation laws,df California, and agree thatifI should become
subject to the. workers'.compe�sation;;provisions/of Section 3700 of, the Labor
Codee.halhfo rtfywitomplwitliose provision's.
Date! 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.
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 4
application.
4
1. Each person upon whose behalf this application is made & each person ate
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•thM the above information is
correct. I agree to comply with all City and State' laws relating to the building
construction; and hereby authorizeerepresentatives of this City to enter. upon
the above-mentioned pro pe rty,for/nspectjon purposes. !"+
Signature ,(Owner/Agent d^' Date
BUILDING PERMIT PERMIT#
DATE C`UATION LOT 0""369 TRACT
L
'" o/V (q/� ��
1►Al�4ii ,00
JOB SITE
APN
ADDRESS 78-".3 DRECK'Is iV11;' I)GE
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M H01 ax ILC
R,a'i' 1A1'V 5.17N.�.(:M, WC.
PO BOO ill C1
14,23 Ls: UkTffE:EZMY DI
LAQuarm CA 92253
PHOENIX AZ 85034
(602)257-1656 CBLO 4.990
USE OF PERMIT
:Poop. ANI>/cap. OK'PA.
POOL & SPA ONL.Y-ALA1tMSl1:d!'r~iL1t1CAS SHALL, BE IN PLACE AT
PR.EPLASUR 1? SPECT'ION.P001, EQUIPMENT ENCLOSURE 1#I NOT
I-NCUIUED ` HIS PERMIT
POOLAI+YEVOR SPA 10,000.00 Ls
T
E.S111 m COSM 01r CONS"11RUCT1'.On
10pw6o
I'1~:RMIr M SUMMARY
PLAN CHECK 1�0, 101.000-439.318 376105
CONSTRII)mlloN Pre 101-000.418-000 `s1111.00
M PCHANICALFEE --P00L 101.000-421-000 $24,00
ELECTRICAL FEE— FOOT. 101-000-420.000 $43.00
PLUMMO FEE -- Pool, 101.000-419.000 $27,00
ti
3U13- MAL. <;O.9.�'.MUC'iMN ,t ND R:f..W C`k 2CK.
x;289.0:5
N D T..l.,SS PRE—PAID MW
$0.00
P -,7p Q Z'23 TOTAL P�.,�2FZFEVESDVE.1ifOW
S289M.
LA
RECEIPT
DATE
BN (
DATE FINALED
INSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Footings
Electric Bond
Main Drain
_ l�
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
co
Final
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
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
Q
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
CC
a.
/ /
( - U
4/9"
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)