0206-127 (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. Date
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 STAT9 C'C?IdII ENSO.4TI Policy No. 0460066168.01
(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 of the Labor
Code, I shall fo 'th comply with those 4%vis9 A..
Date: �.`� Applicant ri_1ae + `J L” Y
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 ion 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 propertyf6l ins ection urposes.
Signature (Owner/Agent)�h� �l{ Date
BUILDING PERMIT PERMIT#
-� TRACT
DATEVALUOITION,�F•F LOT `jZ�
y(idj95
(
f� , rJOB
SITE
ADDRESS79-850 R t vROXa.A QVDI A l 1UW
APN y y
OWNER
CONTRACTOR 1NEyER
�y
.Lid�•1J.CiRI D� V .L•�riO]C MENS
•�/EN
;y/�DESIGNER
�(� ++yoP�q 7�� t �'CO
CALl['�.CMQ�.ri• 2 001.17 SPAS (d VST .iN.i.TiiV COJ
PC) DOX 1716
74725 JONI DXVE, .9UnB ##A
LA -,�LaN rA CSA. 922D
PAIN i7OEUCT C A 92260
c
(760),340-54000 MU 00355
USE OF PERMIT
POOL Abf.L` IOR SP
POOL, SPR. 6 LF, 51 Eii.,CfCK WALL, CITY S'iAAf1~iAidl3
P.MRAME 3 MALL K IN PLACHAT kt-PLASTER Fmilf.MT1 3Ai;
5 rr. WALL 0,00 LFA
`lrAIXTA.` OW ZR,Sv.00 W"
i�:M:II`1�A'TED C,`OVr OF CO?��'.I M('�`.�OE4'
�iD;g3a�3�ir�4l
�qy f`���rp "MARY
I�m.b A �'FjJSnY"., Gii.1iYRZl'.EF RY
MAWFEE
PLAN CHECK FEE 101.000-439-318 $134.55
C0'05 IRLIC:TION RI A 101-000-419-000 O"M
MECHANICAL PER ,- POOL 101-000-421-C-00 S24.0
M.P.CTRICAL TEE d,. _P0011 101-000-420-000 445.196
PI.1M);NO PRE — FOOL 101.000.419-000 $27.00
^.,
p LES49 PRE -PATO F=9
,na
J iV _ . I,Y Mrr 1+".xT-115 Dmf NOW
1 rg Z00?
CITYOFLAQUINTA
FINANCEDEP'T
RECEIPT
DATE -
BY
DATE FINALED
INSPECTpp-
RV
N
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
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
�e92
Bond Beam
Approval to Cover
7— ro
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
_
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sh4- ver Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
2.g Piping
Gas Test
/� .�
d
Lam" - C%2 5
Appliances
Final
- -�
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage 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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