0109-112 (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
0510 .1'i /�S 10/31110)
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 Sionature of Owner
WORKER'S COMPENSATION DECLARATION
I- hereE y 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
6,1 . have and will maintain workers' compensation insurance, as required by
S ction 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.
STATE C OUP 1118 FU 1x'424517-01
(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 tgat if I should become
subject to tP workers' compensatipn prouisions of Section 3700 of the Labor
Code,sha� Ifo with comply with hosePaysons.
Date: l Applicant \ ��
—WarniQi 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, inderi nify
& 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 authori e r presentatives of this City toInter upon
the above-mentioned property f ins ection purposes. �+
11 1A
Signature (Owner/Agent) Date
BUILDING PERMITS PERM TM
DATE VALUATION LTRACT
JOB SITE' r ^^ ^"
APN
ADDRESS
36--700 SAGUARO 1?R:IM
OWNER
CONTRACTOR /DESIGNER tENINFER
Vwp�r-sr-souCdYwr m,, S9WVg
IST -ORM YNT'W0y.12tl3DyL014,010T
77-564-A� C01334'3RY L" IJ- IM 0].13
771-564-A Wi3ITTIRYG"LUB DR, 0113
.rYALM DEEM CA 92211
PAI:. M DES'.I::kt.:3.' CA 92211
(160)408.3495 CB1114 5133
USE OF PERMIT
PZ3OL ARD/C' R FD?a4.
P001A, PA. .ALARMM, A�',.Pt. MS Sf'I,<9.L.L HE IN PLACE: AT PREM—ASTER
1148A' EC;'1" IaK POOL, EQUIPMENT ENCILOS1i13F ASO'! INCIAIDED
VALUA M 1 pub LS
Y FEE SUINTMARY
PjE�aapp
�,,pp e0
101
0 0 f1 4 03
CONSTRUC:T1014 i%El; 10'1-00 19-000 $144.00
MEC1-I.ANICAI, FrE -- POOL 101-000.421-000 $24.00
XLECTRIC,F1.1 ",E—POOL, 101-00"20-000 W.00
PLUMUNG `G+1I -- POOL 101-0100-419-000 $2100
CAT C it'C�C�.I;f�R1 IUM) PS f1Ai C�L�+.C��
$3�3.tSfl
LESS P" PAW FEES
$0,00
r 14 Zpp1 F-1wr FRIts ME NONY
$p%z 3160
SEP
QU1W1A
DEpT.
C� F1oAr►CE
RECEIPT
DATE%
BY
DAT FINALED
INSPECTOR
r.
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade j
Return Air
Steel {
Combustion Air
Roof Deck )
Exhaust Fans
O.K. to Wrap i
F.A.U.
Framing
Compressor
Insulation I
Vents
Fireplace P.L. I
Grills
Fireplace T.O. I
Fans & Controls
Party Wail Insulation
Condensate Lines
•
Party Wall Firewall I
Exterior Lath I
Drywall - Int. Lath ►
I
1
i
Final
Final {
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs !
Electric Bond
Footings ]
Main Drain
Bond Beam I
Approval to Cover
i
Equipment Location
Underground Electric
{
Final I
Underground Plbg. Test
Gas Piping
'�j p lr
Jif
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I
Heater Final
Water Piping I
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
��. d"'� •�
5
Gas Piping
Gas Test ►
Appliances ]
I
Final
COMMENTS:
- ,.otice (Gas)
ELECTRICAL APPROVALS
Temp. Power Polel
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures ]
` • . ' '
Main Service I
Sub Panels ]
Exterior Receptacles
G.F.I. • I
Smoke Detectors I
Temp. Use of Power
I
Final ]
Utility Notice (Perm)