0009-025, 0110-125 (RPL)F1
LICENSED CONTRACTOR DECLARATION
khereby' 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
Professionals Code, and my License is in full force and effect.
License # i Lic. Class Exp. Date
3.56236 C53 w 02/28/ {
Date Z t Ind 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.
(s) 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
Policy No.
STATE FVHD . 076269
(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 ofrCalifornia, and agree that if I should become
subject to the workers' compensation p ovisions of Section 3700 Pthe Labor
Code, I shall forthwith comply with those provisions.] rjrl r
Date: C 1 T 1 Applicant �^--- t t %
l�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 propertyfor inspection purposes i
wSignature (Owner/Agent) i I� r�A .! Date ��r�kv
BUILDING PERMIT PERMIT#
-025
DATE j VALUATION LOT � TRACT
JOB SITE
APN
ADDRESS 45-10000MBROOKLAM
- _
OWNER
CONTRACTOR / DESIGNER / EN (NEER
"BU1v4"GLAG
8U1 wa. P&LB
45-100 COLDRROOK LAWE
44028 ELIMORN 1x2..
LA CIi%I1+iiA CA 92253
PALM DESER'1 CA 92255
(760)340.5521 CBUf 1604
USE OF PERMIT
POOL. AN! - O -ft SPA
POOL & SPA ONLYAL&RUISIBARRIERS SHALL BE 1N PI.ACL AT PRE
PLA.STRR. INSPECT ON, WESTIOLATION ME PER 1997 U..A.C, §304.5
"X)R WORK BECIUN WITH OUT PERMIT.
}BOOL-AND/Ok SP.A. 14,100.00 ISE
MIKA ED COST OF COMR1=170H
14,10D.00
PF.I2IiaY'Y FEE S'i1MMAIZY
PWq Clim Isz? -f 101--000-439-318 %105.30
CONSTRUCTION FA 101-000-418-000 5961.00
mECg1ANICAL Fru;'- POOL 101-000.421.000 $24,00
EI, IXTRICAL FEE .- POOL 4 101-000-420-000 $43.00
PLU1J BINO FEE -- POOL 101.000.419-000 X 1,00
,
INVI STI RATION FEE 101-000-423-000 $162,00
SUB -If b0XS'1 PU(,'�1®2e' ANID K" MY
$525.30
ISS PRE -PAM P'&1~',S
$0.00
T(A'AL FMW11' FFE_8 DUE NOW
$>'�2.'4.30
RECEIPT
DATE
BY
DATE FINALED
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.
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
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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:
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LICENSED CONTRACTOR DECLARATION -
I h4ireby affitm under penalty of perjury 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 Exp. Date
556236 t~5 `1
/C.) qty ' i n t r of ontractor
Date � S g a u e C ._
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.
��yeyectio
1 have and will maintain workers' compensation insurance, as required by
n 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:
Carrierwr
? Policy No
(This section need not be completed if the permit valuation is for $100.00 or less).
(,l), 1 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 towthe
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Sgction 3700 ofjtheL4,bor
Code, I shall forthwith comply with thosOprovi§ions.'., 4 ]
Date: '(,,I :` fl t Aoolicant_-":�,W \;
Warning: Failure to secure Work"erg' Comperisation 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•pursuarAt 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! 7V
j d 11 / j I � �t(�,
Signature (Owner/Agent) 1" �- r�- '�'` 1 - Date tr'1 r /+i'' -3
BUILDING PERMIT PERMIT# .*
"
DATE VALUATION LOT TRACT s
JOB SITE
APN
ADDRESS o-wo cawRi�'i,�omAn
OWNER
CONTRACTOR/DESIGNER/EN &NEER
3!of? l%�5f3ZV3d11!i�3.}:!
si7W>fiS!- POOL9
45.100 (.'O�d'MR- 00K 1ANT
82-762 CI,f R '%k�.M=,X AVE
C I. 92,253
M.Ne"o L",:r1► 92255
(760)275.64.03 t I� 1E04
USE OF PERMIT
:3UF?iZM1(,fd`.tAJ `,'SJ ;F'ER04IT ;9 00%t• 6-25, REM ZVVi3! CI -At;'iION M.
I'iW100SLY K PI.RED POOL L. SPA PERMIT PER CDC W,AA
CKIMSI s RU(111011 AM 101-000-418-000 SIVA
ME.'S.:HAH1C.A,L WE ,. POOL.. 101-000-4211-00f) $xoo
FV?e'TR.1.CA1> f'r1,S •- P001, 10410+0-420.000 $43,OD
PLEIMITING )'"3POOI. A 02 _110(204.19 -(JDA
OCT 112001
C LA OF LA �A
NANCE DF TOF
,
SUB-Tf?TM,1_N'g0MRUC=0)1.raaiAd3 K./
�- 11;;13' AR w1?Aw. R.�:x'`J
$0I OU
;� ) S$Slid .S i.�.i.�i{l,VnL`T.��� .'.S s JJ E NOT9
M.R�SJAi1V
•R
RECEIPT,
DATE/(
DATE FINALED
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.
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
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final i
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)
(.��_ / CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS_ �" l 0D Gal D AOCIC PERMIT NUMBER D /'l 0 - /6'OWNER BUILDER Sc/,-
This
NThis form shall be posted on the job with the Building Inspection Card at all times in a conspicuous_place. On y 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, all information requested below must be completed
by applicant. "On File" is not an acceptable response.
d ::;.:Clas ificati
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Cit ..8 iisiriess
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Company Namee
Classification
License Number
Exp..Date
Carrier Name
Number
Date
Exp..
License
Number
Ex . Date
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(xxxxxx1
1xx/xx xx1
1e. . State Fund, CalComP1(e.9.
(Format Varies)
xx/xx/xx1
1xxxxx1-81
EARTH W O;RK;,1C=121.<:``
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FRAMING>f
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PLUMBING; IC. =361<: ":';<•
LATH:PLASTER:(C351
DRYWALL<:(C=C
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SHEE`T<,METAL`fC=431;:;::: >:
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INSULATION'.IG: Z::';<<<`
SEWAGE: D15PaC=421: >>.
PAINTING.>(C331;
CERAMIC ;TILE: (C-541:`:><:
CABINETS.IC:=61'.<' <: `
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