9808-097 (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. 11
License # Lic. Class Exp -`Date
i2j (1G5 C_53 A/30100
ate -t Ilk 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 licensPri
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,,. tion 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 Policy No.
'71ON ON FILE
(This section need not be completed if the permit valuation is for $100.00 or less).
(V)%- l certify that in the performance of the work for which this permit is issued,
I hall not employ any person in any manner so as to become subject to the
wo(kers' 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 wlthh-tpose provisions.'
ate: 3x� Applicant _�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
A. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and vDid if
work is not commenced within 180 days from date of issuance of spch
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propevjorjor inspection purposes.
t,Signature (Owner/Agent)t�rA'' ✓'. •-` " �Date�'�?�..0
�x
PERMIT # CONTROL #
BUILDING PERMIT'
^.
DATE % VALUATION.)o LOT TRACT . 7 4.6
JOB SITE
ADDRES ' �2V-592 PALL, RM 4 Y
APN
,OWNER
ENNGINEEAR '
CONTRACTOR / DESIGNER ENGINEER
VE
43,692rT1'rt�-1yI+.nEi�,'MOCT
�{l�7��41C�"..gI?.p�PAi�C�;lMCANY 1N.^0'I1.Itl,Iej
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I.R.t�*: IN'TA. CA 92253
RALM',r;/.C-AhMI GS (..A .92264
(760)77. -3939 C BI:,# 2565
k
USE OF PERMIT
r•`Ril7t:..A%iX°)li. R SPA
POOL UNi.Y'v, ALARNi AND Ott 8ARJUER R Oli.i IRI FOR lilt t-PLOOS, 'R P d�� 9
Ir,�►s�c, �'lOty �"'t,
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POOL , NI VOR SPA 10,000,00 i S J
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PERMIT FE E SUAMNIA IIY
PLAN C$WC.K. I'.EE 101-000-439-318 $76.05
CO,N(S'i;N:!:it'T3 .N�.Fb '1!�"01-(0�/0�(0�-4ry18-000 6Ill��"
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1X�f.W-3--11JUN.i��f•Lt,. i , -- POOL 101-000-4..61-.000 - 3.h•.`4.00
j✓LEC RI%E1L $tea ,-- .BOOL 101 --000.420-00 i
PLIUt 034'No £`is'E -- ,i�OOL 101-060-419-000 827.00 .
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SUB—'; -M Aj,, f,;0N:`.aFR C,"I gt:l3d:. ND PLA N CHR .€ K
L- So IJ1s&PA i:b .FrE. s
$0.00
°f19TAL tl'CAti IR FE.S DUB; i4rCAV
8299.ms
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
`� 0
Underground Plbg. Test
Final
Gas Piping �C
Gas Test
PLUMBING APPROVALS
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
-
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
��yv15 Za05 #4&10 Al( GEf?S rt)
Final
`Q
Utility Notice (Gas)
U
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
i
4
Final
Utility Notice (Perm)