0004-293 (RPL)LICENSED, CONTRACTOR DECLARATION
I hereby affirm uncjer penalty of perjury that I am licensed under provisions of
Chapter 9 (commeOJ,50. w!� 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
35105 AG20; f' 0$1'3-1/2(
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:
( ) 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
.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 STATE FAD Policy No. D44-99-00194557
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply wifh.those provisions.
Date: i ., ,00 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 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, 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.
Signature (Owner/Agent) Date_
F1 BUILDING PERMIT PERM'T#
DATE. VALUATION LOT 0004-293 TRACT
JOB SITE APN
ADDRESS 78-5&3 Fmax.5s P"Cwl
OWNER CONTRACTOR/DESIGNER/EN (NEER
MIDR W PIFAM CORPORATION
44.835 DW CAAIYOAI RTS
PALM DESERT CA 42261
USE OF PERMIT
POOL A fOR. SPA
TIERIEAL1 CON UCTION
68-805 P EILFZ ROAD, UC1M -30
CAJ11EDRAL G!T'Y CA 92234
(-160)202-9333 03.11# 00250
POOL. & SPA ONLY-ALA1:.114S/ AlZRIERS SHALL BE 1N PLACE AT PRE
PH ASUR INSPECTION
POOL ANDMR SPA
351000.00 I.S
EgrEVIA D COsr OF CONMLIMON
35,0W.00
PROMM ng SU S
PLAN CHECK FEE
101-000-439.318
$206,03
CONSTPLUCTION FEE
101-000-11 &-000
$317.00
Y
{
MECHANICAL FEE -- POOL
201-000-421.000
$24,00
-
XLECT]R1CAL.YZEe POOL
101-M-420-000
3.f10
PLt1I BI]HQ� , E .. POOL
101-600.419-000
427,00
z
5111 -TOTAL CONS fRUMION AND FLAN (MCK
LFZS PRE -PAID 13'M
* U0TA_1,PE'fflVW'1rX%S DIVE NOW
RECEIPT DATE BY '' DATE FINALED INSPECTOR
5619.05
$0.00
$61.9,465
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
— BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings }
Ducts
_ Slab Grade
Return Air
&teel !
Combustion Air
oof Deck I
Exhaust Fans
K. to Wrap 1
F.A.U.
Framing 1
Compressor
Insulation I
Vents
Fireplace P.L. f
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath
Drywall - Int. Lath i
1
I
t
Final
Final a
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs i
Electric Bond
Footings I
Main Drain
Bond Beam 1
Approval to Cover
I
'Equipment Location
i
Underground Electric
I
Underground Plbg. Test
Final t
Gas Piping (f!
PLUMBING APPROVALS
Gas Test
Electric Final.
Waste Lines i
Heater Final.
Water Piping !
Plumbing Final
Plumbing Top Out i
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral I
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping
Gas Test I
Appliances 1 +
1
Final
COMMENTS:
'
i
Final ;
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole 1
Underground Conduit
Rough Wiring I
Low Voftage Wiring
Fodures i
Main Service 1
Sub Panels ]
Exterior Receptacles
G.F.I. 1
Smoke Detectors I
Temp. Use of Power
1
Final
Utility Notice (Perm)