0001-070 (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
;ZtiaS C10 C20 B 088M;20;
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). �1
() I am exempt u der Section B&P:C: for/this reason
Date 7, 2 ?,lv ` t 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 Policy No. .
STATE 1-111-oD 1412420
(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
.sub�1jec4a, orkers' compensation provisions of Section,3700'of the Labor
�G6c hwith comply(with those provisionsate:•/� 'Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaltiesIand civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to .the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize 'representatives of th6 City tyente pon
the above-mentioned proport jor inspec tion purpos6s.,Sign (Owner/Agent) �= ( �� /�% Date-
d
U*a-`) "" BUILDING PERMIT
DATE VALUATION 57,00 (* LOT
PERMIT #
TRACT
JOB SITE ADDRESS �fY-655 i.:ikLi€ C iPPrd�•4�i$'1�A APN 716,9 6"010
OWNER � CONTRACTOR //DESIGNER ENGINEER
FOaiINp CLcry E ;,Nf
c. .
12 75 (ALLa% QU1'rCJ 83900 AVENUE 45, SUITE C
LAQCINTA CA 9125; iND1O CA.
(760)34? -3M8 C ..B L# 617
USE OF PERMIT
PWL AND/OR SPA
POOL VSs, SPA ONLY - ATr.F1AM40DARRiM , SHALL DG -`IN PLel�.t;,''iC AT
PkW-VLAS Elt 4.tVSir'k:;+-"0.0N
POOL tM/Old SP:a 7,taA010 LS
ti
IB211"FAL C(: NSTCW t(7(1t")N ANL) P!,Att ("114 ICK p4a,� 1
7.L?5S i�aZU-P�11t:f Fr:RS �:4.0>7
!'0l'Aii. ?J,4,9M.r1' E98.!E N4)S!V $244.51)
RECEIPT I DATE
FINALED " I INSPECTOR
'lie i� f x++' E summ �&
PI. AN CHECK F1W.
101 filo-43y 31R
�S�:So!
"
f7C1ns-TR.t u-riom t1- G'.¢?
101-(M. -4 t 4t-fitt
M41 on
=71 iANICAL FEE_ POOL
101-000-421-000
ltl.00
L i 1`R1CAL :irisR -- P00L
i0i-000-420-WO
445.00
t'+t.A f.PVU31t K Plit, -- V( -I'L
401-000.419-000
$21.00
IB211"FAL C(: NSTCW t(7(1t")N ANL) P!,Att ("114 ICK p4a,� 1
7.L?5S i�aZU-P�11t:f Fr:RS �:4.0>7
!'0l'Aii. ?J,4,9M.r1' E98.!E N4)S!V $244.51)
RECEIPT I DATE
FINALED " I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
I BUILDING APPROVALS
. MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Form:5B Footings
Ducts
Slab Grade I
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. 1
Fans & Controls
Party Wall Insulation
Condensate Lines
,
Party Wall Firewall
;,-
Exterior Lath t
Drywall - Int. Lath
}
i
1
Final
Final
POOLS - SPAS
,BLOCKWALL APPROVALS
steel
Set Backs i
Electric Bond
Footings i
Main Drain
Bond Beam I
Approval to Cover
I
Equipment Location
I
Underground Electric
I
Underground Pibg. Test
Final 1
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines i
Heater Final
Water Piping 1
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans I
OX. for Finish Plaster '
Sewer Lateral I
Pool Cover
Sewer Connection
Encapsulation
Gas Piping 1
Gas Test I
Appliances I
f
Final
COMMENTS:
'
'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring}
Low Voltage Wiring
Fixtures 1
Main Service i
Sub Panels }
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
I
I
Final f
Utility Notice (Perm)