0106-362 (RPL)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:, ate
A. C53 IO:C
Date ,� nl Signature of Contractor��?•�
OWNER -BUILDER DECLARA ITIOO Nom'
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 d..Clarations:
( ) 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.
(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 at if 1I should become
subject to the workers' compensation provisiorps'of Section P700 of the Labor
Code, I shall forthwith comply with tho�e..ro islons:7
Date: 4 `'- Z2 r Applicant / f
Warning: Failure to secure Workers' Compensati6n,coverage is unlawful and
shall subject an employer to criminal penalties and divil 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 state that the above information is
correct. I agree to comply with all City, andrState-laws relating to the building
construction, and hereby authorize re �presentatives)1? this City to enter upon
the above-mentioned property for inspection purpo es.
Signature (Owner/Agent) % "/`�-Jc VZ Date
BUILDING PERMIT' PERMT7t ,.
DATE VALUATION LOTTRACT
JOB SITE
APN
ADDRESS79-4279 FIASE0 IJVM
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TIEVE.DO.DSUff CONN CUC TIO NC.
79 -ZIP I-IMEO DEL - 'EY
73011 COUNTRYOUX8 DR, +')i1M, Fri
L.k QUINTA CA 92253
PALMVESERT CA 92260
(7603346 4032 t:-.LRI.+i`l 1 CK4
USE OF PERMIT
Pool., A)MI/ )R U°k A
POOL eg.``SPA ONLY, MMI` %3OES'NOT INCLUDE BLONG°6C'iP�'AI-1,..R�.r9i�iMS
ARR REQUIRED FOR PRFI-PLASTER. INSPRCr'I IOW.
1GMAfiDAXJ..91) COn Or' 1/0,N911SIRAaAd.tid.Y
22RO OD
PL AW CHIRC i 599 101^I:t3O-439.319 $146,::
Ctit33NS11.RUeITION rR19 103-000-1498-000 $u im
MECHANICAL FRE W POOL 101-000-421-000 $24.0
re.LV,CTFJ. A,L FER -- POOL 101-000-420-000 $45.00
PL17MMO MF --FOOL 101.000-419p000 S27 -M
A
wry• ( r A r MIM
A712-41a.4�•L ��.L`�t7 AI.�.W��.
FINANCED
'XXYT'AT, .P 1WJ..' 14MS WENOW,
$167.245
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
K
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs j
Underground Ducts
Forms & Footings I
Ducts
Slab Grade j
Return Air
Steel ;
Combustion Air
Roof Deck i
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing I
Compressor
Insulation 1
Vents
Fireplace P.L. I
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall!
Exterior Lath f
Drywall - Int. Lath I
1
Final
Final i
POOLS -SPAS,
BLOCKWALL APPROVALS
steel
Set Backs 1
Electric Bond
Footings j
Main Drain
Bond Beam I
Approval to Cover
`
..
Equipment Location
i
Underground Electric
I
Underground Pibg. Test
_
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I
Heater Final
Water Piping I
j Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans {
; O.K. for Finish Plaster
I
Sewer Lateral I
i Pool Cover
Sewer Connection I
Encapsulation
Gas Piping ]
Gas Test )
I
Appliances
j
Final
I
I
COMMENTS:
/
Final {
Utility Notice (Gas)
ELECTRICAL APPROVALS
1
Temp. Power Pole I
I
Underground Conduit
j
Rough Wiring ]
j
Low Voltage Wiring
Fixtures i
Main Service
Sub Panels ]
Exterior Receptacles
G.F.I. I
Smoke Detectors i
Temp. Use of Power
{
Final i
Utility Notice (Perm)
A RE -INSPECTION EEE Of $30
WILL BE CHARGED IFTHE APPROVED
PLANS AND !OB CARD ARE NOT ON
l� a� THE SITE FOR A. SCHEDULED
INSPECTION'
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BAL TWEETEN ,
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