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0007-217 (RPL)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (comme; n,g with Section 7000) of Division 3 of the Business and Professionals Code, and m! License is in full force and effect. License # Lic. Class Exp. Date 620775 C53 C27 . -_ C6l3tIfZC / J 613 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. 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 S7'Ai.H FUND No. 1061437-00 ' (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 p�sions of Section 3700 of the Labor Code,ha11 forthwith comply wrth^those provisions. / Date: Applicant' 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 inspection purposes., 01 Signature (Owner/Agent) -�-� i �`"3na'"� Date �� 0 BUILDING PERMIT PERMIT# - . �QO7^,'+�.� DATE �Y EVALUATION LOT TRACT $12XOM _ JOB SITE APN ADDRESS rp,1Z.s _ OWNER CONTRACTOR / DESIGNER / ENGINEER MWFi>Mi_D F1C1WS )DA'17 PALM FMl:. PP1?1MS 3400 CXNTM6AVLONVE, SM; :125 81965 WtINTAW V1..1�.Y�RY 7..P NI EF krVERME CA 92506 LA. QWNTA CA 9225.1 (7&0)351-5300 CIlLif 1888 USE OF PERMIT POOL. AMOR W—A POOL &SPA ONLiC ALAit11>;SWARIZIEk StW L BE IN PLACE.AT PRZ PLASTER, i'N9WTION,POOL FQUIPh4ENT Ela CLOSURY. IS NOT INCLUDED 114 THW PZ!' MIT POOL AND/OR SPA I Z900100W111 FSTIKS11.1j) Cowr OF C0.Nh a!'F+ VCT101%T FW. SU VVVSh"1ty PLAN l''1 ECK FES 101.000,439.318 $87,75 CONSTRUCTION "T 101.000-418-000 $135.00 MECH"ICAL FEE -- POOL 101.000-121.000 $24,00 ELECTRICAL pete, -. Pt;)®L 101-000-420-000 $45.00 PLUMBING IML •- P©OI, 1011-000.419-000 Sx1,00 SC.-TC7.C'.1 L Ct0MMUCiION AND PLAN C'E1RC K $3181) 5 J J= ;p'R. -PATD F= $0.00 TOTAL ]EFAi112:C MU DATE .NOW $318,75 RECEIPT DATE "^`^.BY r DATEFINALED /t INSPECTOR Y� INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts firms & Footings Ducts { b Grade Return Air _ .*.ie Combustion Air Roof Deck Exhaust Fans 0.:: 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 - _ 6D Set Backs Electric Bond _ Footings Main Drain Bond Beam Approval to Cover • Equipment Location Underground Electric p 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 - G'�l 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: