0008-318 (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
Profess 3rimis Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
69M75 C53 WD—, -, 06/30/2(
Date >> Signature of Contractor. t F
OWNER -BUILDER DECLARATION N,,,,
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 STA.TL' FUNS 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 sh II fortwith comply with—.Those provisions..
Date: Applicant----•-
Warning: Failure to secure Workers' Compensati.on'co erage is unlawful and
shall subject an employer to criminal penaltiesna d civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. .
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purpose's..,,,
Signature (Owner/Agent) �- "� 1/ ��'' Date }��%
PERMIT PERMIT#
WBUILDING
,p
DATE VALUATION LOT �"1`�i :i�$ TRACT
� �.18,�70i00
JOB SITE
ADDRESS .3.9ae ,�+�tus
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
3Mnu1'. ) H0]viE3
BATF: PALM 10UMPRISE'S
3400 [`' J RAL AVU–TU s `TrE 32,5
81965 MO1:114TAIN V1L-W !AN -E
RM��f3`IDE C.A. 92SO6
LA QUMTA CA 92253
(960)391.5300 18118
USE OF PERMIT
POOL AND/OR SPA
POOL &SPA ONLY-AI.RSi MS/B ARRIEIZS SHALL BY IN PLACE AT PRI#
PIASTER INOP). CTION.POOL EQU1I'W444 T SNCL OSUR.i 19 NOT 190-LUDKI3
IN THIS PERMIT
POOL.AA DIOR SPA 2 ,pAG.ErA 12
1yy;`SKI ARIM) COST OF C"O1�It5'3".�'f1aXION
10,000M
yy }y�'�y y, yy,, d,•• ��yyyy''
ME, CHANICAL TME -- POOL 101-000-4214,000 62A,00
EL9CTRiCAL 'FEZ -- :BOOL 101.000-420..000 1145.00
PLUI+ MKO VEF -- FOOL 101-000-419.000 427,00
PLAN CHUCK FEE 101-000-439-318 �1aa:ss
CONSTEUCTIO14 FEZ 101.000.418.000 $189.00
yf-t
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t
t+: r i 4 •
M)]3-'.rOTAL CONIS`�t17C` 1010 ANi:S PIAN C LKX
$407.85
} L133 Pxpl-gp } ,�3
$0.00
T IAL PERM'!M S DVE NOW
WU$
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RECEIPT '..
DATE(rBY,%
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set�Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.Q.
Party Wall Insulation
Party Wall Firewall
EMerior Lath
Drvwall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Condensate Lines
F
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
Gas Piping
Gas Test
I Final
Final
COMMENTS:
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power
Notice