0106-067 (RPL)LICENSED CONTRACTOR DECLARATION
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
N W Professionals Code, and my License is in full force and effect.
C M License # Lic. Class Exp. Date
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cZ spate "p Signature of Contractor t 1, �-• '
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J U 0 OWNER -BUILDER DECLARATION
HWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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
M () I am exempt under Section , B&PC. for this reason
in
O N Date Signature of Owner
0)a Q _ WORKER'S COMPENSATION DECLARATION
p CC I hereby affirm under penalty of perjury one of the following declarations:
H Q () 1 have and will maintain a certificate of consent to self -insure for workers'
X W uL compensation, as provided for by Section 3700 of the Labor Code, for the
O Q performance of the work for which this permit is issued.
C3 Q L) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
tl 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No..
Cb 5
Q (This section need not be completed if the permit valuation is for $100.00 or less).
_J (,A certify that in the performance of the work for which this permit is issued,
I Mail 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 provisions.
Die: V Applicant s Vl
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
16-1
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.
1 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.
` 'Oature (Owner/Agent)Y'A oft Date •�"
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0106.4067 TRACT
al ' SHMISKII
JOB SITE f
APN
ADDRESS
45-5M COYMBROOK LANX
- .
OWNER
CONTRACTOR / DESIGNER / ENGINEER
WN & MGMW-9f r
:QE4/rtdE 9WIArM11-TO POOLS
45a560 COLGD1:ROO. &
80-844 BC)ULDF RIR
h <�UD 'CA e% 92M
RMY) CA 92201
(760)347-8789 CBL,41
USE OF PERMIT
POOL, & SPA KlNLY, Pi:t?tlr'IIT DGE`': NCIT INCLUDEBLOCK W.A1,.1.. ,A.LA RM
A Rr 11EQUg. FA) TO BE .1.NIy`t'ATA SSD PRIOR TO RINC A -P rNOPEC' ION
POOL,&N'wop. SPA, I JAM 06 LS
ESMIMIA'fl'i D C4)19T OF C. ONWARIrD'917'OP
1.1, no
MAO €;KCK F&P.' '101-000-4-:39.318 $81.90
.OrSTRtX770114 PEP, 101-000-41A-000, S126.00
YdtsRAiCVVe11__ POOLi01'000-421-000 $24,00
ELF.CTRI :SAL1T?R v -1170 0L 101-000-420-OOD 00
F.LUitrlBINO FEE _ Pool, 101-000-419-000 =00
c
n
0
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i_111M, 0. N MD PLAN C;HROX
$303.90
'L 1,1730 PRE-PfiM PEFS
smoo
FEES DUE NOW
&3W.90
G��0ANG
RECEIPT
DATEBY
` fl
DATE FINALED
INSPECTOR
I
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.O.
Party Wall Insulation
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
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 Notice (Perm)
Final
Final
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
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
Sewer Connection .
Pool Cover
Encaosulation3t—
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 Notice (Perm)
Cold Lno
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
I
PATE BY.