0101-166 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty. of perjury that I am licensed under provisions of
Chapter 9 (commencing�pitha Section 7000) of Division 3 of the Business and
Professionals Code, and=day License is in full force and effect.
License # Lic. Class Exp. Date
01
fid' i3 b40 L
Date , Signature of Contractor t.'a
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 Sianature 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.
(—) 1 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.
SIMM, FUND 15761152-00
(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 f _ rthwith comply with t Esse proigns /a 1
Date: Applicant�h _=, //
Warning: F fibre to secure Workers' Compensation coverage is unlawful'' nd
a.
shall subject an employer to criminal penalties and civil fines up to $100,00,0, 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 Ofj-tb s�application becomes null and void5if
work is not commenced within 180 days from date of issuance of such
permit, or cess ation"of*work-for..i.80,days will subject permit to cancellation.
I certify that I have read this application and state thaftlie-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 dr inspection pur oges. j
Signature (Owner/Agent) ��' Date /dam
BUILDING PERMIT PERMIT #
DATES / !, ] , VALUATION LOT (;'4 Q�j -j�, TRACT
JOB SITE
APN
ADDRESS
78410 TLpNA
•.. ••.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S'LJN ¢dlM D VF1..0PMFNT t ° 9RP,
CAZ. POM41A. AaO(Y'i. 1 & �S'T?.r X
77899 WMAY
74.72.5 JONI DR-T.'VF,, #A,
PALM i ' ? T; :...:...:.... p , CA - 49226&......
RALM TJEiEWr CA 92260
`.........::
(7fs0)340.9000 C} 111 5356
USE OF PERMIT
FOOT.. ANDIOR SPA
POOL & SPA SHAI.L Bit TN Pf_,AGE, AT PR1
PEa,49 lR t;l SPEC1'ft: MPOOI� IIQUIPFv1FNT YN t.X)SUP-9 tS WOT MCL!JEWD ;
IN -THIS YSF'JPMT
PC>01. MIYOR E3PA '14000.00 La
30MA D COST OF 11011MUMO 1N,
PLAN CHEXX ME 101.000-439.316 $111.15
G'ON'WRIUC" ION (PYX 101-000-419-000 $171.06
Ma/.34ANIC-4L ME -- P001„ 101-(M-421-000 $300
Ln.EC'1'R AL ff'=- POOL 101-000-420-000 $45.00
1''S.:L;mmo..1.1, -- P1001, :k,? 101b0"19.000 327,00
b zoo'
'
i Oil
U v� V
AT �- i
:x B-'IiUVA T, COWa11`i UC` 3701sT MD 13T..MI C.E-7RCK
S37 -a.
LESS P1 sPAK) PRES
$0.00
'?'MAIL PERF I $WE ATtJW
RECEIPT
DATE/INSPECTOR
DATE FINALED
✓ ,. �. :-esr' =fes:'.-.
INSPECTION RECORD
t_
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR..
BUILDING APPROVALS
i
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck I
Exhaust Fans
O.K. to Wrap r
F.A.U.
Framing 1
Compressor
Insulation i
Vents
Fireplace P.L. I
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation 1
Condensate Lines
Party Wall Firewall
Exterior Lath 1
"Drywall - Int. Lath f
I
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs j
Electric Bond
Footings 1
Main Drain
Bond Beam 1
Approval to Cover
1
Equipment Location
i
Underground Electric
i
Underground Plbg. Test
Final °
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines ]
Heater Final
Water Piping l
Plumbing Final
Plumbing Top Out ]
Equipment Enclosure
Shower Pans 1
O.K. for Finish Plaster
Sewer Lateral }
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test ]
Appliances I
Final
COMMENTS:
( (/
Final 1
Utility Notice (Gas) ;
ELECTRICAL APPROVALS
Temp. Power Pole ]
Underground Conduit I
Rough Wiring
Low Voltage Wiring
Fixturesfq
Main Service I
Sub Panels
Exterior Receptacles ]
G. F.I.
Smoke Detectors ]
Temp. Use of Power
{
i
Final
Utility Notice (Perm)