0108-204 (RPL)N U)
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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
Professionals Code, and my License is in full force and effect.
License # Lic.,Class Exp. Date
Date �n # !t Signature of Contractor 44 i 1
OWNER -BUILDER
I hereby affirm under penalty of perjury that Vam exempt from the Contractor's
License Law for the following reason: J
( ) 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 Policy No. y���N*q "1203-3
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1�R.t+;' ON 1, i�.l'flK0. b G WON "1 Ma -3
(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 Cg(�fo�nia, and agree that if I should become
subject to.,the workers' compensation provisions of Section 3700 of the Labor
Code, kshP fo with comply witht4ho"e pr'o isions.
Date: #�! 1 / f Applicant—
to ��
Warning: Failure secure Woikersr Comp�ensation coverage is unlawful and
shall subject an employer to criminal,
afties 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.
(.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 authgrize representatives of this City to enter upon
the above-mentioned property for irispection purposes.
t Signature (Owner/Agent)• -t+ '� fu ° : Date'l) 1
t
BUILDING PERMIT PERMIT#
DATE 1 VALUATION `46i ()ICS - 204 TRACT
JOB SITE
APN
ADDRESS
V-1.30 COMM, LAIC
.. ..
OWNER 4
CONTRACTOR /DESIGNER / EN (NEER
IR`,l`D1.iFT64!M.3.,di'f.Xi9 A OMT0, LLC
ROE ET ATNSWORIH POOL CONIT .UC" O
LA QUIN°TA CA 92253
PALM X)EMT CA 92211
(760)568.4993 Midi 15115
USE PERMIT
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POWS'PA.ALARArf Ai232F�9�.�tM:fALL UM P ACIZ?AT PR&P a =YR.,
iNSP E<CU014. POOL MUAt''M4ZNT 1:K1405URE NOT MC:LYI DED
Pf3 L Md: OR SPA 24000.00 L,J
11MWT 1 i si Y
PIM CKWK FOR 1X13.000-4339-318 $36:1.30
4MRS TRUC T10.H .); 1014004 1 &000 $32.00
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MECHANICAL FEIC .- POOL 1€1.000-4421-000 $84,90
rE,1r 'Ifi.I4;;" FIFI f:.4 POOL 101-000.420-000 $45,00
PLUMMO FEE POOL 301.000»-419--10 $27-40
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9-3�3-'l�i`� �13C7C�Q�i� AN�S PLAN C �11a�;�"
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MOS %SAM FEEM
1$0.00
1 2001A
gFIN—ANCE
QUINTA
DEPT.
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RECEIPT
DATE {>
:BYDA
FINA D
INSPECTO /
UL
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
Set Backs
Steel
Electric Bond
J
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
PLUMBING APPROVALS
Underground Pibg. Test
Gas Pipingip?J
Gas Test
_ �T
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:
s!3al
:,rty Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condult
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)