0211-082 (RPL):-:JClfzD CONTRACTOR DECLARATION
I hereby affirm uI)der pe Ity of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Busindss and
04 co Professionals Code, and my License is in full force and effect.
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J U OWNER -BUILDER DECLARATION
HWd I hereby affirm under 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
M (;) I am exempt under'Section , B&P.C. for -this reason
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O N Date Signature of Owner
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U Q 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.
0 1 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 STATE ;x4.fNn Policy No. 00 '?'1! 1
(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 w 'ch this permit is issued,
I shall not employ any person in any manner so as become subject to the
workers' compensation laws of California; apd.agre that I I should become
Subject to the workers compens tion provisions bf. actio 3700 of the Labor
Code, I shall forthwith comply wit those provisions. s ,
Date: ! t -Applicant Cy,ti �'
,
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 to 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 wil -subject permit to cancellation.
I certify that I have, read this application and Ote that the above information Is
correct. I agree to comply with akCCity, and tate4aws relating to the building
construction, and hereby autho 'ze repres tatyves of this City to enter upon
the above-mentioned property f�r inspecti9fi purposes.
(Owner/Agent)
BUILDING PERMIT
DATE VALUATION LOT
JOB SITE Id
ADDRESS '7 7_.1N CA,;;.;A VE1, SOT -
OWNER
DAVDLFIST 3Av. Z C..'OA1 MICU(.°^"1014
1', ),11OY, 17'7
LA QUIN CA CA 92253
USE:OF PERMIT
T`001, PAff 0'_R MA
fY�:Y'.t.• t3in
TRACT
APN
CONTRACTOR/DESIGNER/
T.f.O. BOX 3 7 2
:Cap. QIRN'TA CA 9::25:3
(760)275 -3820 (31AF 1 Q309
POOL, SPA, VIR914f (496AOAL), ALAR.MiSlBARtUER'S .3H,AI,L b& 1N
PLryryf,:vf��`[`.I?}^Ar: s�'ryF�j;,P..-;�I„i�.r"TL�'i�t. �3�is:�.t'"i'i�'a?f. 4?Ai11l��rlfs�'► t?NcM!:t);lt.t¢,.t�.1�t?`a'
POOL, ANL'iOR VA
15,000,00 W
►y /(�,yy ''yy����Y-L yy 7�r}� SMA
hh���/. $�d;'9'I�,� AIRD COST O.0' C.0I'�iS'fRUCHO:V
d. Krl'�.:4i`6i,1 #/ IEE l71:L'i'.f.13Y.1A RY
T^LAN t`HEClb FEE 101.000-439-318 S105.30
CONS'i'g.tT+:."I' ON PEF 101-000-d 13-000 $162.00
MI FIC1lANICAL, _FEE _ Pool, 1101-000,421-000 $24,00
9LW,TR1C-A1_ K?, --= POOL 1 WA -WO-420-000 t45.00
PLI.1MBY9r_t IRE -- POOL 101-000.419,000 SVIOP
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A Ula i' '11+:f (°(• f1"Tt7Tt�ilral�l AND PLAN(:T1r,-,,0X
I � .L1 WAS PRE -PAD Y-FT3''r
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T,.PFRAM FEES 1)Ur, NOW
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT DATE/ BY,* rte^ I DAJE FI LIQ // INS: R
150Yr).M_
$0100
0631390
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
SLOCKWALL APPROVALS
Steel
POOLS a SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
PLUMBING APPROVALS
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
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECT=AL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltzge 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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OF LA QUINTA
HU ING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
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