0006-354 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H r- Chapter 9 (commencing with Section 7000) of Division.3 of the Business and
WProfessionals Code, and my License is in full forca and effect.
O =) co License # Lic. Class, -Eip. Date
I Qu)
11�
LLJ �t;��/CS4J f3
o Z Date'. Signatureo_f.Gontractoy._
(DDOo
J
(D OWNER -BUILDER DECLARATION
W W I hereby affirm unde'r penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
ON
0)d z WORKER'S COMPENSATION DECLARATION
o LO C I hereby affirm under penalty of perjury one of the following declarations:
O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
max: i
m
J Q perforrnance of the work for which this permit is issued.
Q(� OrI 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
a rn permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z CarrierPolicy No.
P.A?
ab Z) W. COMIY' OFT WD817004109
�a
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'mann r so as to" become subject to the
workers' compensation laws of California and agree.thatrif,l should become
subject to the workers' compensationpp o)9ions of 6ection'3700 of the Labor
Code, I shall forthwith compl'y`. with those provisions., P
Date: /� f� Applicant i f �-----
j' 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 persomat
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 Cit�,and StaieRlaws relating to the building
construction, and hereby'authorize�representatives of this.City to enter upon
the above-mentioned propert f r.innns'pectio"urposes.
Signature' (Owner/Agent) !Dat'e7 —2''
(lBUILDING PERMIT PERMIT#
DATE VALUATION LOT �• TRACT
S10,tid10di0 40 253 «3
JOB SITE +
APN
ADDRESS 78-99!. J3.RF Lr.K. WGF, DRM
769-OW608
O,VNER
CONTRACTOR / DESIGNER / EN (NEER
1'o BOX 810
1425 & UNIVI�'RBnT 1 F-
LA QUbrrA CA. 92253
P14011 IX AZ 85034
(602:)257-1656 4ML# 4990
USE OF PERMIT
POOL. AMVOR SPA
RE
POOL &SP.A C)NLY A ARMSI£ARR.IM SHALL SA IN PLACE ATME
PLASTER TNSPEC'iION, POOL EQUIP ENCL.(iSt1I3F 13 NOT INCLUDE 1) IN
THIS PERMIT
POOL ANDIOR SPA, 18006.00 IS
ESMI4l ED OSS` 01P 0(3IdS'i UCITION
101000.00
t"'EI&M Is"KR SUMMARY
PIAN CHECK ITE 101-000-439-318 M.05
COkJS't RUC"TIO' 4b FEF 101-000-418-000 $11;.00
bAECHAMCALFEE •-POOL 101-000-421-000 $24.00
I - L 101-000-420-000 $45.00
01AHINO FEF POOL
PF101-000-419-000 .00
8i}:k340 AL CONSTRUC110R ANE,+ AM CY=1:
VW03
1:.ESS 'ME-PAU)V -,S
$0,00
TMAL P_kV .1t'( FR :S WE N ow
$289,05
i -
RECEIPT
DATE ``By
/ "
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
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS
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
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:
C
v
�► 9,
f
07
GNno� c
i � 1
w -1 wrlrww
FOATE(e30_
OF LA QUINTA
A RE-INSPECTION FEE Of $30 G & SAFETY DEPT.
WILL BE CHARGED IF THE APPROVED PROVED
"k PLANS AND !OB CARD ARE NOT Oil
;HE SITE FOR -A SCHMILE�i ONSTRUCTION
INSPECTION. gy
.NO EXCEMONS.