0005-081 (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
Profes5ionals=tAe, and my License is in full force and effect.
License,# Lic. Class d Exp. Date
6S612f3 C53 10131/Zt,
Date 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: -'4
( ) 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). Ilk
() 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 31'A` 9 FUND Policy No. 046_00-000068.00
,(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,
tl 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 those, provisions.
Vate: Applicant—
Warning:
pplicant 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 property for inspection purposes.
.Signature (Owner/Agent)/-^. Date
,� n0 BUILDING PERMIT
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.-
6APERMIT#
C JI
DATE VALUATION '-+'. LOT TRACT
�,C1(10.t3ai3
JOB SITE -
APN
ADDRESS _ 78-062 C LJff� 1g0KT
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ER �O l
CONTRACTOR / DESIGNER / EN INEER
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CvATIFORNIAP00 ..8 �' S M
78-K" -E 140KEE
74-725 J01M DRTVF-, #lis
1JA QU It t CA `_'''2f,'
PA1.1v1 CD]+S',ER'i CA 92260
1 Z 4 p�
(��:0�3�10..9a00 CM -6355
w+ .
USE OF PERMIT
POOL ANDIOI? 9PA
POIa1, & SP,A CtL-Y - ALAPMSiBAS MIOR.3, SHALL 8Z fN PLAC9 AT
P11E•PLA3'T3?R l;? OPECI'ION,
POOLAND/OR SPA. 4,009,00
MUM !. CO INT OF CONb, MIU'CTION
4,000.00
I'.EMITrT,.9iJ?ui'me1RY
P'a..AI4 CHECK 1 101 -000-439-319 X10,45
CONS7'fB.UCTILYN FW, 101-000-418-000 $63.00
,
MKCHANICIAL FEE •- POOL 101.000-421.000 $24.00
Ef. EC*TPJCAL f Z •• POOL 101 -MO -420-000 145.00
PLUMB114Q FEE - POOL 101-000-419-006 $27.00
t+ai
SUB TOTAL COi+TST UC LION AM) PLL CREEK
9.95
$199-95
LEA 39 rRr"PAMFM
$0.00
" TOTAL plMM FEE$ :DUE NOW
r
RECEIPT
DATE
BY!
%t>rr
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUDDING APPROVALS
MECHANICAL APPROVALS
SeNBacks ! (
Underground Ducts
Forms & Footings 1
Ducts •
Sia b 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 :1
Condensate Lines
Party Wall Firewall [
Exterior Lath
Drywall - Int. Lath s
i;
1 I
Final
Final
BLOCiKWALL APPROVALS
steel
POOLS - SPAS
Set Backs !
Footings i!
Electric Bond
Main Drain
Bond Beam
Approval to Cover
_
i i
Equipment Location
I i
Underground Electric
Final {
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines i {
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out ;
Equipment Enclosure
Shower Pans i i
O.K. for Finish Plaster
Sewer Lateral I
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances {
Final
{
.s
1
Final
Utility Notice (Gas) ! i
ELECTRICAL APPROVALS
Temp. Power Pole ' i
Underground Conduit i }
Rough Wiring
Low Voltage Wiring i
Fixtures {;
Main Service ;
Sub Panels ; {
Exterior Receptacles
G.F.I.
Smoke Detectors )!
Temp. Use of Power
li
�i
Final
Utility Notice (Perm)
COMMENTS:
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