0204-012 (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-Busirtess ar!C"
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
191192 C5:3mo
Date ti �� 271"Z Signature of Contractor >` r�c'tal^–
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 EXEMPT. 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 provision/s.
Date: 41-1– 7L-,.7 Applicant `7.,e 4 / G1
/ i I
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit; or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspections purposes' •
Signature (Owner/Agent)% ��°' Date- 2L'G's$
BUILDING PERMIT-__"iPERMIT /t ,
f
DATEj VALUATION LOT TRACT
�" i.1,a�c�.t;�
JOB SITE
APN
ADDRESS _51,—.x•0 C.tkT.ri(eF')?AL01k
— —
OWNER
CONTRACTOR / DESIGNER / EN (NEER
t}fJ 1` i
RESO:M11,110O:i r
23315 SYLVAN M M
9 83 0 1AFMCY RD #'I
WOC+1:X_AWD k1 1,0 CA 9136?
SAN DIEGO CA .9,21-" A ..
(6'19)261.4527 G.131.
USE OF PERMIT
Y10t':iL AN"DJOI';. SPA
POOL AND SPA 034LY. ,ALARMSi1SARRIRRS SHALL RX 114PLACE ��t IOR
TO I'RUL,A.81ER II?1SPEC-110N. P001.,, RQ1`iEPMEWT FXCIbSURE WO1
R4C1,.OD1!D TN PERMIT,
POOL) AND/OR VA. n060DO.00 L21
e 'r
FsS MdL.'1eM) CO.Mr 0F CO1'i6'I.IRUCTIUff
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20,0MIX)
PIERMT FEE SOMMM '
P11AN CHFICK FE )01-000-439-318 $134.55
CONS'd'1"t'UCTIOi1 YHE 101-000-418-000= $Xyl. U0
MFC4.t NICAL nF -- .POOL, 101-000.421-000: 124,00
E-L:f,XTRICAf.,FEE .• POOL 101-•000,420-000 445.00
PlIUMf111a1O FER P001. 101-000-419-000 11 "P.d10
AIL
+/ WYORAQUINTA
01TB-rc3A.N L CC51<8MI0.1C'.l'IONWD 1CkW CHisc"`K
a417.55
IMS PRE -PAID FM
0 o
_ TOTAI, Flia?Xfff Y +fes• S DUE NOW
T424 7,V5,
RECEIPT
DATED
%
DATE FINALED
ATE
INSPEC R
fT
+t.,r
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs r of
Electric Bond
Footings
Main Drain
`
gond Beam
Approval to Cover
Equipment Location
Underground Electric
j C22 -
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
p3 /v
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
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
Final
Utility Notice (Perm)
COMMENTS:
17f' -
CITY OF LA QUIMTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE B�iz .
r
NVILL bt AKUtU 1� I H,t Arm t
PLANS AND -JOB ARE NOT'O
-007L
NVILL bt AKUtU 1� I H,t Arm t
PLANS AND -JOB ARE NOT'O
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im -.�rrru
"Vi I
-CARD
THE -SITE FOR A SCHEDULE[va
-kilISPECTION.
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7
NO EXCEPTIONS'
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APPRO. ED_
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FORdbN
CONSTRUCTIOoN S
DATE BY
m6a$ "ou
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7
memgoo y Road. Sults 7 Sanj)Lego, CA 92129
SHEET
(858)549-260
OF' Si
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CITY OF LA �QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS PERMIT NUMBER I OWNER BUILDER
This form shall be posted on the job With the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this.list or their employees are authorized to work
on this job. Any changes to this list must be approved by the -Building Division prior to commencement of work. Failure to comply will result in. a stoppage of work and/or the voidance
r,f h..ilrlinn narmit I=nr annin nnnlirnhla trnrla all infnrmntinn ran.iactorl haln,nr m.ict ho rmmnleteri by annlir.ant_ ,nn File" is not an arrentahle re3nOnSe.
Trade / Classification
Contractor
State Contractor's License
Workers Compensation Insurance
City Business License
Company Name
Classification
(e.g. A, B, C-8)
License.Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varices)
Exp. Date
(xx/xx/xx)
s
License Number.
((x�xxxx))
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
W%2
ECl
CONCRETE (C-8)
_
FRAMING (C-5)
STRUCT. STEEL (C -51)2D
I
MASONRY (C-29)
PLUMBING (C-36)
-3C110
LA'ffi; PLASTER (C-35)
IV
1 `J
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10)
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING (C-1.7)
?
INSULATION (C-2)
SEWAGE DISP-. (C-42)
PAINTING (C-33)
a
.
CERAMIC TILE (C-54)
CABINETS (C-6)
FENCING (C-13)
LANDSCAPING (C-27)
POOL (C-53)
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