0210-011 (RPL)LICENSED CONTRACTOR DECLARATION_,
I hereby affirm under penalty of perjury that I am licensed undbrr provisions of
Chapter 9 (commencing with Section 7000) of Division.22'of the Business and -
'Professionals Code, and rhy License is in full force.and.effect. .
License # c PLic. Class101.3112C
" Exp. Date� g 9 r
-53
Aate Signature of Contractor
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
c-
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 SITI � y;Ur;j Policy No. 229w3ZX•01.
(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
subject to the workers' compensation p ovis,.•lo n�of Section 3700 of the Labor
Code; I shall forthwith comply with those pro�l bns.
Date: 10062 Applicant •��• - a!�� r
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.
r
I certify that I have read this application and state that the above information is
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
/e'a'bove-mentioned property for inspection•pdrposes.
Signature (Owner/Agent)r Date/,�lir %t 01
BUILDING PERMIT PERMIT#
DATE 1.0120r2r VALUATION te� e LOT y TRACT
t�
JOB SITE
ADDRESSI�`�lu%F�iIiE�°�t,�LA��a�i�'�
APN
._
OWNER
CONTRACTOR / DESIGNER / EN (NEER
•'S 9.8 r, 5' TiMCHO=3AWF`t LPE
62,930 RC%CK1riYOi OD'eMIr„r?,016, ALloM
1,A QUKYA ;"A 9 2 2 5 3
1i,/>;pINI—D.UMMIr CA 92261
C!60)349-.8400 CBvi�-0470
USE OF PERMIT
1:"00 .: ANIDfOR IPPA
POOL, 140,SPA. ONLY. .Ai..A..FlMSlleA4ZF IPRS SMALL. AF. I-fs F"LACE PRION.
TO PRIEDLA•'SpT�IM INOPECTIf�M ;I�001.3"4�.►13':1'PMMY �''N LOOCI3tENOT
1NICLIMM IN P.EILMIT,
Pool, ANDIO ? SPA tau
ENIM"1'�@l'.'I3 C oYr 01t' Cf)2�`.>;1`CE:TMON
rE 1ilD• m sI;.ihnil.� v,
PLAN C} KKK FRIX 101-000-439-318 $194.03
CONS'iT"UCTF:ON FEE 1.01-000-418-000 $294.50
ta+1ECHAMCAL M -., .AC1OL 101 ^000.42,1 -000 WAR,
ELP-MRI w.,,i'f6 .. POOL9 a.w-000-t2UMoi3..t•; $kli:Ub
p1.1.1mmAi671*x- P650L 101-000-449-000 ; e r.oa
A
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0C 1' 1 1 111AII
CIyyOFLAQUINTA j
FINANCE DEPT-
. �i:1'x3-'1C�',"AIL M'JNM9CTX)N ;ASND Pl.,A T CMCK
I iss PRE-9pAm 11tF.2;S
$0.00
111MA6; P:�'.Rmrr 1' NY's DUKIN MZ55A,,3
RECEIPT
DATE j
BY[
—"'""
DATE FINALED i
-� IS-
INSPECT
C:..
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
� ]--Oz'_
Set Backs
Electric Bond
Footings
Main Drain
—r9z
Bond Beam Z
Approval to Cover
Equipment Location
Underground Electric
/ 2
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas TestElectric
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
Gf# Piping
Ga`s Test
Appliances
t
Final
COMMENTS:
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)
i
I 3, L.F. 1_
(-ITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED.:
FOR CONSTRUCTION
Dam