9804-044 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under of that I am licensed under of
PERMIT# CONTROL#
BUILDING PERMIT
penalty perjury provisions
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Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
DATE VALUATION LOT 9894-0''�'� TRACT
8782
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Professionals Code, and my License is in full force and;effect.
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License # Lie. Class Exp. Date
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CSbtZ€1. C 53 /'10/31/48
JOB SITE
ADDRESS 79-910 CASA DKIa Filth
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Date: f r ?T,'{� Signature of Contractor t -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
OOWNER
-BUILDER DECLARATION
T.D. DESERT DEVELOPMENT
CALIFORNIA, POOLS & SPAS
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
P.O. 1303 1716
74-T25 JONI DRIVE. 4A
License Law for the following reason:
LA QLfIi` TA CA 92253
PALM DESERT" CA 9221+1)
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( ) I, as -owner of the property, or my employees with wages as. -their sole
(760340 -WO t'BL1. 355
compensation, will do the work, and the structure is not intended or offered for
USE OF PERMIT
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).
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O I am exempt under Section , B&P.C. for this reason
.SPA ONI , ALAI<MSrdA1ti ERS ARE TO AE OPORATIC.YNAL Pr<.i AR TO
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ON
Date Signature of Owner
l N-CAPIPRE-PLASTER INSPEC710N
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
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() 1 have and will maintain a certificate of consentto self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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( ) I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
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CIS 5
Carrier Policy No.
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3TATF UND 046-98-0000168
ESTIMATED COST OF CONSTRUCTION
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(This section need not be completed if the permit valuation is for $100.00 or less).
PERti`fdT fiEE SUMMARY
( ) I certify that in rthe performance of the work for which this permit is issued,
PLAN CHECK PEG 101-000-439'31.8 $32.63
shall not employ any person in any manner as to become subject to the
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workers' compensation laws of California, ally agree that if I should become
CONSTRuc 1"lON FLE 101.000418-000 $Sl.i►U
subject to the workers' compensation provi ons ection 3700 of the Labor
NI C HANK AL ,FLE -- POOL 101-000-421-000 52i.lit�
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Code, I shall f Pt with comply with those p: vision
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ELECTRICALFEE -- 17"O . (01-000-420-000 5;,15.Ui►
Dater % Applicant
PLUMBING FEE -- POOL 10114MA19-1000 i3'.Qi1
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
SUB -TOTAL CONSTRI[K.MON AND PLAN CHECK
$220.0
& 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
LESS PRE -PAID FEES
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.
TOTAL PERMIT FEES DUE NOW
S229.65
1 certify that I have read this application and state that the. -above information is
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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 above-mentioned property for in j�ection purposes.
RECEIPT
DATE
�'
BY /
DATE FINALED
INSPECTOR
Signature (Owner/Agent) Date
NSIPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BBL DENG APPROVALS
MECG;AN5CAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab,orade
Return Air
Ste6
Combustion Air
Roof Deck
Exhaust Fans
UK 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
SLOCKWA L APPROVALS
POOLS a SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg, Test
Final
Gas Piping
PLUMBWG 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
Encapsulation44- -j
Gas Piping
r
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECT=AL 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
U ility Notice (Perm)
COMMENTS: