0207-203 (RPL)'LICENSED CONTRACTOR DECLARATION s
I hereby affirm under penalty of perjury that 1, am licensed under provisions of • BUILDING PERMIT
Chapter,p'(commencing with Section 7000) of Division 3 of the Business and I DATE t" VALUATION LOT
Professionals Code, and my License is in full force and effect.'`"�
License '# Lic. Class Exp: Date a JOB SITE y
ADDRESS �9�.. 4., 0.+�i'.�rt� ��
' S
Date 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:
(( 0)) 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 71 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
pe mit 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).
1 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 thosefproVisions.
Date: Applicant °-
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 1s 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, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Z'Signature (Owner/Agent)
.�f
Date
OWNER
DOMKIC & HOLIX, NAPM.
?9-? s99'PA,' 3s0 :i M FXY
LA QUINT.-% CA 9225:
USE OF PERMIT
POOL.MmfoR SPA
PERMIT#,
TRACT
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67 - X03
APN;€?...«.; l
CONTRACTOR / DESIGNER / ENGINEER
4'3WKER - MyIS, )Err
PfJ0USPA .AJ,.AR.MSy"R.ARPIZPZ SHAL1. BE IN P SNC E AT 'PR1.&'i,.A.ITRR
114SPECTION,€ZNCLOSURR NOT INCLUDED [TPA1'.I'?E ASSESS PER
1997 UAC §304.5 'FOR b°V'ORK BEGUN WJO ELDO. PIAT.
POOL ANMR. SPA M0000 Wri
E&TDAAM COST Or OOl4?511R€J OS'
PRRM.I ' :6 EE SUMMARY
PLAN CHECKE, 101.000-X439.318
C:C3N4.I'FRUCTION ME 101-000-41€4-000 itfi9.a?f3
MECKd LAICAL F'WL -- POOH, 101.000-421.000 $24.00
EIZC TRICAL F17 -- PCI0,L 101-000-420-000 $45.00
PLUMBING OUZ -- POOL 1016000.4.19 -WO $27,410
rMV'13T10JVE'1'0V FEE 101-oiD00-423-000 $189,00
J^y+SUB-TOTAi, CCDPd'S''fRUCITON' AND PIAN (41 -DY -M,
. AVg ; ,ESS TIRE -PAID FMI
Ttom, ..P=a& ' FKIKS DUE NOW
J6). i'. /' ue
CITYOFLAQUINTA.
DANCE DEPT.
$596.8`5 • •4
RECEIPT I DATE �r BY ° ,.,,. I DATE FINALED INSPECTOR -
v
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
r
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric BondZ-
Footings
Main Drain
— o
Bond Beam
Approval to Cover
jp pZ
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING 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 I- `N
Appliances' `
Final
COMMENTS:
Final
Utility Notice (Gas) i
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
ow Voltage Wiring
abdures
.(,Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
in #
[Permit
City Of:La' Quinta
1 -Building k Safety:Division
P.O.;Boz 1504;`78-495•Calie Tampico
La Quinta, CA 92253 - (760) 777-7012
Building .ermit Applicationand.-Tracking Sheet
#
Project Address: °� �_ ..
� Owner's Name: 1-iYi�lG )
A. P. Number:
Address:-. R r
Legal Description:
Contractor:Tel
Address: �r
,Cit) ST. Zip: — (� l� C
' hn
eP< X.
Project -Description:
City. ST, Zip:
Telephone:
P on e.
State Lie. # : :City Lie.
Arch.., Engr., Designer: &A
Address: Dv .
Ciy, ST, Zip: C Gl !' D 1lLw��T
PAi�4ll
TeleP h one:
€
Co ' '
'st u c uon T - P e. Occu P ant �•
tate i #
S L c.
':Pro' ect type (circ one): Neww A dd'n Alter Repair Demo
Name of Contact Person: (� y
Sq: Ft.:.
#Stories:
its:
Telephone # of Contact Person:.'P.3®'� , ?>r ..
Estimated Value of Project: l�� D0O
"APPLICANT: DOw.
.NOT',WRITEBELOW .THIS LINE
#
Submittal
Req'd',
Recd
TRACKING�k•
PERMIT FEES
Plan Sets
Plan Check submitted .
Item
Amount
Structural Calcs.
`Reviewed, ready•for corrections
Plan Check Deposit
Truss Calcs.
Called Contact -:Person
Plan Check Balance
Title 24 Calcs.
T1 n" picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd Review; ready.for corrections/issue':
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans'resubmitted
Grading
IN HOUSE:-
''d Review, readv for corrections/issue
Developer Impact Fee
Planning Approval
• a
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
w LNI/��
� 8 � , 00
School Fees
yi7 S
's
Total Permit Fees
r
3% CITY OF LA QUINTA SUB -CONTRACTOR LIS_ T
lf1�G ��
JOB ADDRESS / PERMIT NUMBER D2,v7-2'63 OWNER BUILDER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this. list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to,;commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information,requested below must be completed hy:aop icant'. "On File" is not'=anvacceptable response.
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Company Name
Classification
License Number
Exp. Date
Carrier Name.'
Policy Number
Exp. Date
License Number
Exp. Date
(e.g. A, B, C-8)
(xxxxxx)
(Wx'x/xx)
le.g. State Fund, CalComp)
(FormatYaries),
(xx/xx/xx)
(xxxx)
(kx/xx/xx)
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OWNER/ BUILDER INFORMATION
Dear Property Owner:
An application fora building, permit has been submitted in your namelisting yourself as the builder of the property
improvements specified.
For your protection you should be'aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required,to be signed by property owners un'les's they are personally performing their
own work. If your work is bung performed by;someone other than yourself, you,`may protect yourself from possible
liability if that person applies for'the proper permit,in-his or her name.
Contractors are required by law,to`be'licemed and bonded by'the State -of.California and 6.have'a business license
from the City or County.. They are also required'.by .law to put their..license number on all permits for which* they
apply.
If you plan to do your own work, with the exception of various trades that you "plan to subcontract,. you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family and the work (including materials
and other costs) .is $200,00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be,an>employer.
If you are,an employer, you must register with the State and Federal.Government,as.an,employer and you are.subject
to several obligations including- State, and. -Fede fal income' tax wit hhoWin g,`federal social`. security taxes, worker's
compensation insurance, disatiiliry" insurance costs and unemplogment comp' ensaiiomcontributions.
There may. be financial risks for you. if -you' do not carry our these -obligations, and ,these risks are especially serious with
respect -to worker's compensation insurance..
\ \ '