0309-274 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of_
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
O =) co License # Lic. Class Exp. Date
I w
656128 Ciao i /r 'kl,,. 10/31/2(
oZ r— Date ! ?" } Signature of Contractor`
(� Q•
J U 0 OWNER -BUILDER DECLARATIO
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section B&P.C. for this reason
In
N Date Signature of Owner
ON
0)
d< WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
Oro _ Q performance of the work for which this permit is issued.
Q (� (°� I have and will maintain workers' compensation insurance, as required by
O U Q ectioh,3700 of the Labor Code, for the performance of the work for which this
d L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier TATE C:'OMPHNSATI Policy No. 046-6104003
ao
0
J (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
i 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 those provisions. {�
Date: elv s Applicant �lr ./,-
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;--`§uch
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 nspectionygposyes.Signature (Owner/Agent) Date++
*, ' -BUILDING PERMIT PERMIT#
i1-2�•9 ”
DATE VALUATIONp LOT TRACT
$17, 9n I+y wai 86 ..
JOB SITE _
ADDRESS 4W-211P0�I�9i M71.'dAPTI AC�� , —
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
91-W--, t1 HMM -
C)UMFOFiMA FOOTS A UP AS Cr0P MAN COI
81-260 AME, 62
86•1€10 AWNUE 54
LA QUMA CA 92883
COAFILA CA 92236
(760)398.9222 CSL9 00355
USE OF PERMIT
POOL 1 NDIOR SPA
POOLAPA 11.4 L.N. 5' H1(' H BI.AMM WALL CITY STANDARD -
FT. WALL K00 LF
POOL, AND/OR SPA 17,675.00 LS
E :IMATED COSY OF CONSTRUCTION
tt'PYRAW Y I'E 9U)MIARY
PLAN CHECK VU 101-000.439-315 $122,33
C`ONSTR•t1C" ION FEE 101_000_415-010 $189,00
MECHANICAL FEE --POOL 101 000.421-000 MOD
L'LECTRIGA.L F2Z .. POOL 101-000-!i20-�C 00 $45.00
PLUMBING RE � POOL 10.1TOOO-419.004 �;v''Y.00
,"SUB -TOTAL f K AND PLM t"'-�kff,G!fw
'LCs 1 •X35
.O-1M1",E2.UC'Ya.+v
------ - - - IMS,ul _PATD FMI
$0.00
I.1sAi ri'iny t:5 7 U -E Now
I�s�
-SEP 2 5..200,
CITY Or i—A QUIN1 A
RECEIPT
DATEEya
BY / p y
DATV ED �'`
INSpE6yOR
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain _
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
pSewer
O.K. for -Finish Plaster
Lateral
PooLCover
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
Appliances
Final
-T
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)
COMMENTS:
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