0007-118 (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
P�ofeas a, *s Code, and rry License is imfulj force and effect.
License # Lic. Class Exp. Date
.476807 C53 06/30/2(
Date -� f Signature of Contractor. - •!-s~.� - -~
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 STA'T8 SND Policy No. 2*00 UNIT 0020404
(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 shall forthwith comply with thos-e`rovisio
Date: —J&—a- Applicant A -�
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 Section3706
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'nspection-purpos s.
Signature-(Owner/Agent) - K t Date�%��TLl�`i .
" PERMIT PERMIT M
DATE LLOT Q7-ix8 TRACT
LOT
//J/&rVALUATIONBUILDING
.
JOB SITE/ / I
ADDRESS
w
APN
fP im-vo Dp
_
OWNER
CONTRACTOR/DESIGNER/EN (NEER
JORK Jf 1tROHATA.
A QUfi CtZ7)-,& ' PC)OLB
79-3631*itT VO DRM
80-975 WD10 BLVD.
L,kQUJWA CA 922S3
PALM DESERT CA 92253
(760)345.5070 CBIA 130
USE OF PERMIT
JYNOL.ANT. AMR, fTA
POOL & ,SPAS. ONLY-ALARMSI3AP-RIERS SHA'IA, BE 1W PLO.CC AT PRE
PLAOTER. INSPI?CT ON,POOL EQUIPTu RNT YNCLOSURE IS NOT MC'•LLI(aED
IM THIS PERMIT
FOOL AAI1~I S''P.A 165:000.00 i..S
3E8'1i'� `FED Cii :i OF C)0NS�'i1'�3Ur1fa1R
kyr
� 302Ei�UAil AR.Y
PLAN CHECK FEE 101-000.41 9416 $111.19
CONSTRUCTION 1EF 101-000-418-000 $171,08
XECHANICALB -- POOL 101-000-421.000 $24,00
91XC9 TICAL FEE .- POOL 101-00"20-000 $45.00
PL>w MBINO FFE •- POOL 101-000-419.000 1".00
:111B-'Y07A' -CO `1MUMOX f;.N :PL.I4.N CINMR
$378.15
LnS PRE-PA[D FUS
$0.00
� 01 PERIM'PT.VS noT 0W
r
RECEIPT
DATES
`
DATE FINALED
INSPECTOR
1
P OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Sei 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
Steel
POOLS - SPAS
gt7
"
Set Backs
Electric Bond
7
Footings
Main Drain
8 -
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
�p I
Underground Plbg. Test
np I
Final I
Gas Piping
13
O
PLUMBING APPROVALS
Gas Test
Electric Final
e 13-,
p�L
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
Encapsulation
p
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:
W
PEE 0P $30 KK N"
ARE-INSPECT101� TBE APPROVED :... ,. r K
:VdtLL BE CHARGED ARE NOT O� Dwelling f ��
.. s. AND )OB CARD - � r
PANS SIT E P OR A SCBEDULEO
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LJohn Hirohata y r r
. i -. ♦, f .Z K N Y Y- I
79-363 Neuvo
La Quinta,Ca 92253 ' �' a;►5
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Pal+�wDe.�w't,Cc , 92255 �� 6'7 5
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` Ucr# 476807 - Blockwall