0012-122 (RPL)H
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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 �' 7 r ~ 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).
O I am exempt under Section , B&RC., for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I havw 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 carver & policy no. are:
Cartier Policy No.
(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 provision of Sectiip of the Labor
Code, I shall with comply with the �a -
Date:' �` v Applicant'
Warning: Failure to secure Workers' Compensation coverageis 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'
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, indemnity
& 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 permit10 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 herebyauthorize repre atives of this City to enter upon
the.above-mentioned property for' se l
Signature (Owner/Agent) r Date %
BUILDING PERMIT PERMIT#
'DATE VALUATION LOT Qll�. TRACT
1.2JtV20C 114lThi! C�(i
JOB SITE
APM
ADDRESS 79-51% M SM.IEZ
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RUSS Rti`'''1.OR
mi aA!'L`YRE MINA :I`SPAO
79•-595 CORUM,'LxWE
P.01 BOX 1191
LRQUftTrA CA 92253
LA, Q'lYffA CA 92231-
CbUt
USE OF PERMIT
1001.1 fel D/M HPA
1001, &SPA ONLY/ttA.ld.ltlERS SifAL4• HE lig PLAC e.A T PRE -11.1%S ER
FHOPlrt'TIOW, POOL 1!OUf1aMROT +"CI.,,CA:f1.IRH:.19 W(YT MCLI:JDW)11v1.1`HV1
IT
PERMIT
POOL ANi>/OR 3PA itt'tSitl.09 '°
XS�A'lT6Xr .D COW Old' C'ON9TRUi"1fTUfii
2.tDi{li10 eo
'PERA SCd`T` IM SUMMARY
PLA14 Ci1FtX "X 101-000-439-318 R1.1%.55
CON n -A RUCTION FEE 101-000-418-000
MEC't1ANICA1,FEEf POOL, 101.000.431.000 VIA, 00
15LLCTRIC.A1. FEK- POOL 01 -600-420-000 $43.00
PLUMBING FL?L --POOL 101.000,419-i 00 527,40
0(M -TC 'CAL. Cl?Ad;1.1`kLTC1'P"M AM .ISL A14-+"`FMCK
$437.5:
LE9 M -IRATE) FIMMI
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rvTm, Pm rr. mm Dvx now
RECEIPT
DATE
BYDATE
FINALED
INSPECTOR
I����'ECTION RECC���
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POO(L.S e S PAS
LBLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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
ERC Cta->P ap
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
1#114 Notice (Perm)
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO EIRMONS1
cChink Stone Spitway
K.4
3 6;!
+0. Planter
+18" -Raised Bond Beam
3-9-
ouatctte Gold 12" water line
\ �—
2400w Pool Aft Filler
e)
-tit) gross Units %p I "; I I ivime ross uumiul—A
LLa Quinta CA 92253 Fax: 760-360-3435
717/00 for: La Quints CA 92253