0007-244 (RPL)U)
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LICENSED CONTRACTOR DECLARATION
I hereby aff;rm unde-4 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 a_nd,effect.
License # Lic. Class-" f Exp. Date
690645 'BImc IA ,. " i � 6%30)2(
ate`' ff )-hi:"� Signature of Contractor •�'f'�` _ __,
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 rt43, CdMP.A`t4y CSF 3' Policy No. WDE17t,1? I"D
(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 Californi as nd=agree that if I should become
s ject to the workers' compensation provisions of Section 3700 of the Labor
Vode, I -shall forthwith compljith•those provisioijs,__-,�
Date:Andfii-.-nnt� -
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 that the above information is
correct. I agree to comply with aII,Cit,�and, State laws relating to the building
construction, and hereby authorize repres.entati es of this City to enter upon
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above-mentioned property for inspectionpurposes.
ature (Owner7Agent) 7 � &te u�
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)10)60 BUILDING PERMIT PERMIT#
(0)'7
ATE VALUATION LOT TRACT
Si(7,E3f��At)
JOB SITE
ADDRESS „ Cj�►mSS:jOJN
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APN
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RXr 1 VEMI&P NTS, i c;.'
PXf ROfFrM W11S,1TC.
1425 Z UMVM,3f_rX DRIVE
1425 F. U 4WERB rX DMI
1•'9,01m3; AZ: 8504
1410mm AZ 85034
(602)257-16.56 C.B141 4990
USE OF PERMIT
;POO..L ARDI ?R �3 A:
,
POOL ASPA ONLY-ALARAAMR1 IBIS SHAL1. BE 1114 PLACE AT
Pct-PIASTFA WSPFCTION
VALU,A LION 10,0tI0,00 LS
EgImA"%:.Im C.os".r oy cons Rucn'ow
101000/00
Pkwl&r M SUMMARY
PLAN CHECK FEE 101-000-439-318 X105
CONSTRUCTION DEE 101-000-418-000 $117.+00
MECHANICAL FEE -- POOL 101.000.421-000 $24,00
ZLEC'I PPCA .,, FEE — POOL Y01-000 420»000 $46.00
PLUMBING =- POOL N 101.000.4.19.000 Iwo
AUG IQ ZEN
s � 'r
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$289,05
.TOTAY, PEOMMES MES �RQW
$2W._015
RECEIPT
DATE
BY y
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
POOLS - SPAS
Steel -
Set Backs
Electric Bond
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:
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE G v BY
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT 0
THE SITE FOR A SE ED
INSPECTION.
NO EXXCEW"PTI
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