9808-075 (RPL)H
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under 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 and effect.
License # Lic. Class Exp. Date
o501 28 C53 (* ; 10/1103
Date �— R 5�'14signature of Contractor. -� , �V
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt • from the Contractor's
License Law for the following reason:
( ) 1, as ownerof the property, or my employees with wages as their sole
compensation, will do the work, and the structure isnot 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 Policy No.
k'f>.Ti.;1+UND 046,-91t;4'4)0 t68
(This section need not be completed if 4he permit valuation is for $100.00 orless).
( ) 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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with th se pro6slon . i.
Date: � Applicant�T
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the. cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney"s fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and-6tate laws relating to the building
construction, and hereby authorize reprie2ertatives of this City to enter upon
e above-mentioned pro for ifs,( i, n purposes.
Signature (Owner/Agent) v Date —$_
BUILDINGPERMIT PERMIT# CO` OL#
DATE VALUATION �!) �!� LOT TRACT
J436
JOB
ADDRESS SITE ;3.875 CAAA DEL RIO
APN - -
OWNER
CONTRACTOR DESIGNER ENGINEER
•r>>
CAiyFpi\NlA I)1,S.p �"PAS
P.O. PDX 1716
74-7125 iONI DRIVE, M
LA QUINTA CA 92253
PAL; DESERT CA 922(,0
(760)340-9001) (,',(?l,f' ;155
USE OF PERMIT
P0oL)kK,D/oi( SPA
1;
INX)L Ol`ii Y, & AR&I AND OR 1 RAKER REQUR21:. FOR P.R&'Lt• M 1 A
IN5!'E 110N PA 1 D
AU
11
POOL AND/CR SPA i 1.°iUcl.C3 1 s
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LA'(DUINT
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DsST1 'lATEDMSf'OECONST44WHON
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PER -MI T F Uir S U M 44 A11
CLAN(:W, ..0 PEE 1l)I.-W04-19-31.3 $l4S.3t1
t"{ztv3'f'Ri,rt_'Tft��d4�t�i (111-1j(m.JI>�-0�1 �:4h;',i1()
NI C HANK .A FEE • PQ( 1,. 101-000-421-000 SN.00
hlEC 1kiCti1, FI -E --.K <jL 101AM-420-000 $45.t u
P LUMBINO FEE— K)OL 101-000-419-000 S.27.00
S'1JT.s-1TJ A1✓ CONSTRUCT A,ND MAN CIS fi3CK
$36310
LESS Pftl.-PAID FEES
$0.00
TOTAL O' E IVIA11 F E EN DUE NOW
$363.30
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
NSPECTM 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
FA.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
BL®CKWALL, APPROVALS
Steel
POOLS a SPAS
-/
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBNG 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
G ,
Final
Utility Notice (Gas)
ELECTROCAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lora Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice (Perm)
COMMENTS: