0305-142 (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
^77 9165 AB MC
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 r _
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 STATE FOND Policy No.
(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 forthwith comply with those provisions.
Date: r.
Applicant—
Warning:
pplicant 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 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 property for inspection purposes.
Signature (Owner/Agent) l %- r - -�"'- Date
BUILDII�u PERMIT PERM'
��
DATE ,,. VALUATION LOT TRACT
JOB SITE ✓ I ' '
APN
ADDRESS 5&078 aAPALMeS4 DAUME
OWNER
CONTRACTOR / DESIGNER / EN INEER
MARK B0'VEWZ1
GA1`7M4'45,W PC3't)LS
56-078 PALM DRIVE
2295 & TAMMISKIRD
LA 0,U1NTA CA 922.5:3
PALM SPItC.NGS CA 92262
(760)778-3700 MILD 2951
USE OF//PPERMIT
���� YY7r� �@pry�
P\. 01. B:t1sWOR SPA
PaU,t, SPR, BBQ ISLAND, BBQ(ANSi Z2id5B). ' AL.AP.MS/BAtT:.RIERS
SHALL BE 1N PLIbOEAT PR&PIASTER INSPWTION, EQUIP ME141
ENCtDSURF,14'0T INCLUDED
POOL.AND/OR SPA 20,000.00 LS
ES't'MATED COST OP' COud+YMUCTl.O
2Q,Ci�U.tsO
P + MT FXE b"QI.O/MARY
PLAN CHECK FEE
001413 RUCTION FEB 101-000-418-000
MECHANICAL FU -- POOL 101.000.421.000 124.00
EI_WX,' TPJCAL M .-POOL. 101-000-420-000 $45.00 '
PLUMBING FFE POOL 101.0004419-000 S27.0
p �
D
2003
rel M9.9 PRE -PAM FEM
$0.00
TOT'.t►L . E-RAH.17 rims DUE ROW
S 4.3 7,56
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
•i d ,
j,.'r 1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs i
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade
Return Air
Steel i
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap I
F.A.U.
Framing l
Compressor
Insulation
Vents
Fireplace P.L. i
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall 1
Exterior Lath
Drywall - Int. Lath I
;..
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings i
Main Drain
Bond Beam I
Approval to Cover
-
Equipment Location
1
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final "
Plumbing Top Out I
Equipment Enclosure'.
Shower Pans
O.K for Finish Plaster`.
Sewer Lateral i
Pool Cover _
Sewer Connection l
Encapsulation
Gas Piping
Gas Test i
Appliances
Final
1
Final
Utility Notice (Gas) i
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring }
Low Voltage Wiring
Fixtures I
Main Service i
Sub Panels I ,
Exterior Receptacles
G.F.I.
Smoke Detectors I
Temp. Use of Power
i
Final
Utility Notice (Perm)
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