0009-211 (RPL)LIC _v CONTRACTOR DECLARATION
I hereby affirm undi 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 EX/Plate
,r' 638335 B `
/ e.
ODate I X:57'" ` Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's !F
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 tie 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.
(f:)` 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 STATE FUND . Policy No. 2290-CODP671
(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 Se tion 3700 of the Labor
Code, I•shall forthwith comply with'rthose provissions.
'Date: Applicant
c'✓4,' Applicant
Warning: Failure to secure Workers' Compensation coverage Is unlawful and i
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 Seotion 3706
of the Labor Code, interest and attorney's fees. /
IMPORTANT Application is hereby made to the Director of B ilding and Sefety
for a permit subject • to the conditions and restrictiorts set forth on4his
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 pursua tt to
any permit issued as a result of this applicaton agrees to, & shall, inde unify
& 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 6f.,such
permit, or cessation of work for 180 days will subject permit to cang�llation.
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 authorizejrep reseggtatives of this City to enter upon
the above-mentioned property -for inspectiotfpurposes-..-
Signature (Owner/Agent) X, +� Date
BUILDING PERMIT PERMIT# f
DATE - VA"TION LOT �`�-� TRACT
'JOB -SITE
ADDRESS .5"10AVEMA JTYAI
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
PO '12 BROXERB
L TIMI i, VwriJRT l WC.
,4,054-4 10 AVI.fiT DAJUAREZ
70.00 CAI.. E='ADO, UCil'L'R 2034
LAQTJINrA CA 92233
LAQU fA CA 92253
(?f(3j554�Ib6G CBL•I� �35�
USE OF PERMIT
POOL AND/OR SPA.
POOL & SPA r)NL,Y- ALARMS%RkRRIFR,S StiALL ])E NA.A.CF A`f
PRE-r-PLASTF13 INOPKTION, BLOCK'IFlr'ii14 KA, POOL EQUIP:MI±.NT
ENCLOSURE IS NOT MCL,UE&D IN THIS PEtL` IT
POOLANDiOP. SPA 191000,p0 La
EST:�1V.IATX13 COST 01.r Cont" 'Ucnoiq
� 2.0;- 001
yq �q'��'�� Fry7�;��� �`�p�7�,�',�p'.�
Sri[31�.6ar ice.+' l7ilJ�yiiY.�t'l z 9 #
PLAN CHECK FP -1s )01-000-439-318 $31,90
CONSTRUCTION FM 101-000-418-000 $176.00
MWHANICAL. FEE -- POOL 101.000-421.000 $24.00
M ' =1UC!l L FEE •- POOL 101.000-420-000 $45,00
LIUMBINO Fr,,E -- POOL 101.000.41.5.000 $27.00
SUB-TOU-AL. CONSTRITC11ON ANIS PLAR CTil-.+'.:K
$303.90
L)5213 PRE-PATDP=
$0.00
TOTAL 1?'Kl::t' I`.E8 DIXE NOW
9403,0
RECEIPT
DATE
D
INSPECTOR
�
V_
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Steel
Return Air
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
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)