0203-399 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty_of�erjury 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
t' Exp. Date
3FIf4 C53 rcp
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, 7444, Business & Professionals C:nrfP).
( ) 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 -- �-;L t ::7'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 ofection 3700 of the Labor
Code, I shaJI forthwith comply with thos provisignw-
Date:'Applicant' �^
Warning: Failure to secure Workers' Camp-ensatlon CCverage'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) ,�'<F"= - ' ` " Dated
BUILDING PERMIT PERMIT#
DATE f, /off ,vALUA ION, LOT TRACT
JOB SITE
ADDRESS f8 -7,S0 ORTOIN WAY
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
1, xv1 B0EIG at
Ct i C;OMRANS 1?WL COMM"
A
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1.A Qu.4 ITA C A 92-653
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L�['�UNA e).c.7,v..tLVC�S C A 96s.4AA.
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(6,19)32a,2030 MVI, 4816
I IAF nF P_FRAAITi
POOL. A%IDAi.'R :PA
POOL AND SPA aNL`i'•..AI,:A. INSAIARRIER.S SHALL, eE IN PLACE MOP,. .
TO PUP ASTUR DISPisCTI[ON, POOL Ec1Ud;i'MENT F14C'LO-SURF, NOT
1'IdCIADED I'M PXR-MIT,
FOOLANDIOR SPA 32,6Q0.00 L°
EaNTFUM&, CO.S-r OF C0119R"F:.I7MON
3i �+1 :311�E3d?
PkIMLT FRE SUMMARY
P1AN CHECK N;4E 101-000-439,318 $19%.Q
CONSTRUr ION FEE 101.000-2.18-000. $291.50
luF1rG'F IMCAL FFE -- POOL 101 *v000421.000 E24.40
ELMY'1 WCA L Aft.- PL' kOJ, 101-000-42.0-000 -000 °$45.00
P1,rLfMBrWO ME -- POOL 10,1-000419-000 1127,00
r,
C 'C11111091 MD X_ t -T MEolk
$586.68
LMS 1PRE-PAM FEES
$0.00
MAR 2 y 20OZ
RECEIPT
DATE
BY
DATE F ALED
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.
I Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel —i —
Set Backs
Electric Bond
Footings
Main Drain _
Bond Beam
Approval to Cover
Equipment Location
Underground Electric y �z
Underground Plbg. Test /� 2
Final
Gas Piping _y
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Heater Final
W titer Piping
Plumbing Final ,
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation 1 -
Gas Piping
-
Gas Test
Appliances
Final
COMMENTS:
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 Nance (Perm)
CITY OF LA QUINTA SUB -CONTRACTOR LIST'
:JOB ADDRESS PERMIT NUMBER OWNER BUILDER
--f his form shall be posted on the iob with the Btzildina 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
of building permit. For each applicable trade, al; information requested below must be completed by aDDlicant. "On File" is not an acceptable response.
Trade / Classification
Contractor
State Contractor's License
Workers Compensation Insurance
Cit License
Company Name
Classification
(e.g. A. B, C -S)
.Business
License Number
(xxxxxx)
Exp. Date
(xx/xxlxx)
Carrier Name
-,(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
Ixxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK IC -12)
CONCRETE (C -B)
t
s
g O�
FRAMING (C-5)
STRUCT. STEEL (C-51)
MASONRY (C-29)
PLUMBING (6-36)
1; PLASTER (C-35)
DRYWALL (C-9)
HVAC IC -20)
ELECTRICAL (C-10)
6i00FING (C=39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING IC -17)
INSULATION (C-2)
t
SEWAGE DISP. (C-42)
�'
i
PAINTING IC -33)
CERAMIC TILE (C-54)