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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (comm3ncing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class ^""! Exp. Date
690645 B�,1:IZM Ak `' 0613012(
ateSignature of Contractor j
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 w.o, COMPmIY' or- T Policy No. WDS170041900
(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
s bject to the workers' compensation p�vyslons of'Section 3700 of the Labor�
ode, I(9hall- orthwith comply with th se,provisiaris!-
ate: �j tr�� 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 can
I certify that I have read this applicatiomand state,that the above information is
correct. I agree to comply with Cityrand+Statteflaws relating to the building
coir gtruction, and hereby authorize epresentatives of this City to enter upon
t e above-mentionned,property�for inspectlon'purposes. /
Signature (Owner/Agent,' ' gate
16 / ' BUILDING PERMIT PERMIT#
DATE VALUATION LOT W07-241 TRACT
JOB SITE ,
APN
ADDRESS w62o cypimssrom
_
,OWNER -O'
CONTRACTOR / DESIGNER / EN (NEER
Pur WVMMI-wo, naC.
R3T »MMIM, Ric.
1425 Fa VNIVERSI'1'Y DRIVE
14251r T.?2 IV1MIMY D-
p.,LI(1M4LSi ALI 93034
P11110MlTX AZ 85034
(602)257-1C)i56 MR 4.990
USE OF PERMIT
POOL, A1+ID!= 811A
POOL & SPA. ONLY.Al,.ARMftkRJii,125 a KALI,, HZ IN PLAC J,? .A.T
PRE -PLASTER INSPECTION
VALUATION 10,000,0012
COST Off+' CO.IV�a�'.1�i71C,*I!'k(' N �
10,0�00.{l0
.�y ,�y�+ �g,g �991L�f.!A.l:
d kSLt!'.6,LI M, SMIMM R 9.
PU.N CHECK FEK 107.000-439-318 x'6105
CONSITRUC TIOW FSE 101-0,00-4111-000 $11?.t1tl �
MECHANICAL FRE - POOL 4 01-000.421-000 $24,
EL1.t'MICAI, IEEE —&BOOL +` 1(8 ••000-420-000 $45.3
�. PLU114IRINO I;'EP -- POOL 1()1.000.419.000 827,00
AUG 10 2009
SL113-7O°M COW"MYCIAOR AND FLAN' Ci tk
$269.05
LESS FRE-FATI IFM
$0,00
n
RECEIPT
DATE
BYE/'
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
'J. 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 I I
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:
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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)
.4 s
F
ITY OF LAQUINTA
ILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE BY
I
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO EXCEPTIONS!
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