0108-319 (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
Prplessionals Code, and my License is in full force and effect.
-License # Lic. Class Exp. Date
656128 C53Yff.' . 4133121
Date Signature of Contract 0 1AA
„t„ f
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.
e ),,.I have and will maintain workers' compensation insurance, as required by
tion 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:
Carver 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 pro I ions. 1
Date: 4'.'��A Applicant jt
Warning: Failure to secure Workers' Compensation co'4erage is unlawful
shall subject an employer to criminal penalties and civil fines up to $100,00
addition to the cost of compensation, damages as provided for in Section 3
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Saf ty
for a permit subject to the conditions and restrictions set forth on is
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 sucli
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 propeply for Inspection purposes,
A,
Signature (Owner/Agenty.� t Dates
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01M1319 TRACT
VXOM
JOB SITE
APN
ADDRESS
3300 IM V:A10
'-
OWNER
CONTRACTOR / DESIGNER / EN INEER
K114 VIVA DE"itk OPM1i4'' h' CIC&P.
(W.1 '°'CRNM MOLS & SPA> S CMP MAW C01
77919 W<;aU
747 25 JONI DRIVE, MURNA
PALM „UN= CA 4226-0
PAI ISI DFMT CA 922611
USE OF PERMIT
POOLAND tY1 "I A
5 .
1'r9':f4.9.Z11 oTPA'f"UPUE; SLIPP)ZMENT-A 1, TO PIPI<'Uid T 0106.062
1001..,Pa1+1;[11t" R 1,i'PA ?,000.90 is
EMMA,= COW OF COINb"i.".R�7� �°1�O
E
i
�t,DiSCTb#�€➢
y,�r�q,�� ,�yyk'�
PLAN CM?` *K FEE 101-000-4,39-318. $29.23
CCINS?`d:UCTION FEE, 101.000.418-000 5450
E11] YR1G; U RTI •- POOL, 101 -WO -4,20-000 $45.00
PLUMBING FKEKF• - POO,.." q 1 QI �E2d?f?�`s 9 r1-Od?C3 �? J.tlt1
r�Y
AUC 30 2001
IT OF LA QUINT A
NAMCE DEPT.
nSTl,B 1MPLA NE�+�"f':K
$146,25
, FRE -PAN) Fs
$0,44
DI ... 0W1J'TXCNDUK,£i'Ow
S146°121.5
RECEIPT
DATE
10-10 J /
BY j• j'
j «! _
DATE FINALED .f -
51 IX
INSPECTOR
Iii
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
-
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
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
62
Gas Piping
Gas Test
Appliances
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)
Final
COMMENTS:
_