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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Cha ter 9 (commencing with Section 7000) of Division 3 of the Business and
" PrNssionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
ti5f�x.2€► C53 i 013112(
Vale t ( 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 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:
Carrier STA4'E PUND Policy No. 046- OOD6163.00
(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
wor ers' compensation laws of California, and agree that if I should become
syl§ject to. the workers' compensation provisions 0Section 3700 of the Labor
ode, I s6all4orthwith comply with those provisions...
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
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 ab ve-mentioned property for inspection purposes.
L Ignature (Owner/Agent) + Date
`'{` BUILDING PERMIT PERMIT#
DATE VALUATION LOT li W.5-100 TRACT
051W.00 38 24517
JOB SITE
APN
ADDRESS 44-365 CAM'10
! 604•491-018
OWNER
CONTRACTOR/DESIGNER/EN (NEER
RA> }CHO OC"UMLO LP
CAT'.�MRNCAPt OLS & V.AS
1:535 00. ly SIT�nE-T;: 0200
74.725 ON['DRM, 4A
SMBMWARDINO CA. 92408
PALM 1�1..,S.i+,:ft'.► CA 92260
(760)340-9000 CBM 355
USE OF PERMIT
'EATS 7L7 .�T . e i ilTl3 J
J
WCHO OCOTILLO POOL &3PA ONLY SHALL B
114 P_ 1CFs..AT PR&-PLASTEP, msPF:CTION
VALUATIOIN }9,Oa0 Ob L3
7!:9MA.U01: `1(im CG.! .I' (
MMT FKE 9CIAMARY
PLO CHECK F&P' 101-000-439-318 WS130
CONSTRUCTION F!KE 101.000-418.000 $162.00
11 ECHANIC.AL FFF..-- POOL 101.000-421-000 $24.00
LELF TR ICAL FEE •• POOL 101-000-420-000 $45.00
PLU1J11 R40 FEE -- POOL 101.000-41 MOM $27.00
BUD -TOTAL Cf,°OAISTRIX3'.ION' A.ND PLAN CF190K
�3S3.3Q
L&SS PR&PFTD 13:13
$0..0
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RECEIPT
DATE
BY I
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
Set Backs
steel
Electric Bond
'
Footings
Main Drain
Bond Beam
Approval to Cover
Ejquipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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)
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A RE -INSPECTION FEE Of $30
WILL BE CHARGED IF 114E APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTIORL
.NO MEMNS
CITY OF LA QUINTA
BUILDING & SAFETY DEPT
APPROVED
FOR CONSTRUCTION
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