7504-045 (RPL)LICENSED CONTRACTOR DECLARATION
uj I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
CV W Professionals Code, and my License is in full force and effect.
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/ate wSignature of Contractor ` �`t
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U°� ? OWNER -BUILDER DECLAR�jATION
CD
LU W I hereby affirm under penalty of perjury that I.am I3xempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
rn
Z WORKER'S COMPENSATION DECLARATION
p 2 (1:
I hereby affirm under penalty of perjury one of the following declarations:
FZO () 1 have and will maintain a certificate of consent to self -insure for workers'
X w Y= compensation, ,as provided for by Section 3700 of the Labor Code, for the
O J Q performance of'the work for which this permit is issued.
m Q U ( ) I have and yell aintain workers' compensation insurance, as, required by
V N f j- * iJdrl y 4"F1",4-4 � ;
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
tl Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
ao D
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J (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 -to"become subject to the
workers' compensation laws of California, de that if I should become
3 subject tg the orkers' compensations V visions of Section 3700 of the Labor
Code, S 1 9� ul h comply witholo>t pJovisions.
,Date: ti Applicant } r'
Warning: Failure to secure Workers' Cimpensation 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, indemnity
�r�Vip & 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 r , resentatives of this City to enter upon
{ the above-mentioned property f _''section purposes.
Signature (Owner/Agent) `11 f� Date ����
a
BUILDING.. P RMIT:. PERMITeii:;"4-J)4� � CONTROL#
4115/9100 �.3E 312 6
DATE VALUATION LOT — TRACT ..
JOB SITE'
ADDRESS
01NER�N,C, f t,
=14096 000TILL0 DR
LA QUINTA CA
7712-600.
USE OF
POOL EWWOR SPA
APN
CONTRACT•O / Dyr4N
ES GER / ENGIfJEER
4 r.lrL3cr),s, (55NS.rnucrioN
33?�iIO AVENI.DA T AI 11R.F.
92253 I.A. C}1?1j TA, c'�A 922S3
{6:i9;1�cu1.-36'0' C'1F,# 2Q93
10,300.00 L9
FSTINISFED COST OF CONYTRUCTION1
1011M0.00
I?h.HIM 11' Fle,t',SV!lMAXV
PLAN CHECK Ffl
11011-( 439-318
Skii.�(1
CC1bF8TEtVC'fION I -'FF
IN -O0 -.4!a-010+!1
t:atr
t :.IWN4CAL FEE -- S004,
101.0000-121-000
$x.00
Fzf CTR(CAL Ft: -- POOL
10)14)0.4207-000
$45.00
PE,i l IBI W V BE -- POOL
10 1,.0M-4.19-00110)
$27.00
Sl111 'trsd'AL CItJN`r1213Ccr.6T# AND PdJiw CMIir f303.90
LESS PRF -PAM FI S 50.00
I
APR1 ('..199 I�
6
13
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
OX 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
Electric Bond
Footings.
Main Drain
Bond Beam
Approval to Cover
-
Equipment Location
Underground Electric
ly
Underground Plbg. Test
z
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
7
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Qi
Gas Piping
Gas Test
Appliances
Final
'
COMMENTS:
-
'
j
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit ir
Rough Wiring
.Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
W ity Notice (Perm)
4
6'
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13, at—do
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34' i.
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1Y OF LA QUNTA
a{ DING � SAFETY DEPARTMENT
CONDITIONALLY
ACCEPTED F®R.C®NSTRU TIO N
SUBJECT TO INSTALLATION AS PER
� 0.
wA APPLICABLE COD
7
AND
-- -__ -- --- % 1 DATE BY
WOLFE RESIDENCE-
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44=®90 0cotillo
772=6002
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Construction
Pools Spas Fountains
*(69)1564-3655
Lic.4658996'
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VA