0206-107 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
(65.6128 C53 MC C -t ` '10131/2(.
Date Jam,' �* Signature of Contractor—
OWNER-BUILDER
ontractor 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 37.00.-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:.
Cartier STAT. COMPENOAT.1 Policy No. 0460006t 68-01
(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 thosefprovisions.
Date:4 i' iy'ry,, Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensati7coverage,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 forinspect pure ses
Signature (Owner/Agent) _ f Dater
PERMITH
t BUIL-DING PERMIT
,�,�,11 a-x�
DATE VALUAiicth, ti1R.�S,,w i,� LOT TRACT
.44
JOB SITE
ADDRESS ✓ M427'-14FA1`1'�.8.>T BAY
APN � R
OWNER
CONTRACTOR/DESIGNER/EN (NEER
2280 VIAML'; W MCM, VMS 150
'747205 JONI Yi 3=,, #A
CORONA CA 91720
PALM DESERT CA 92260
Q60)340.9000 M4 00955
USE OF PERMIT
OL..A.M/CR, VA
POOL? ..SPA, OAS AND ELZCTPJC 1JV_ E.S FOR FUTURY, 88Q ,(M431
nka&PLASI'fEP.INSPE-CTJOH.. QUTPRtZEN� ENCi,O9UAR1a0T 114MUDIM,
"lirA1.T.➢ATION LS
WnMAIED COST OF CUNMIf7�.- ON
18, %w
PRIM= M AYMMAIRV
P401 CHE CK AZE 101.000.439-315 $128.70
CCIA19i' UCTION FEE, 101_00"1113-t00- $19&190
VFC)iAi`t1CAL FEE -- P0(XI, 101 M(SE' 421-000 $24,00
ELWTIUCAL ME ;:.POOIL 101-000-420-000 045.00
P'L13i1r5S1Ad1'1 FER. - PO, OL 101-000-$19.000
r;
SUB-TAOT.A.L, C010TRUC i" 010 AMM PMT CF=t
$422.70
7. U249 TIRE -PAID MES
1ALM.Paw Y?'xr s 7M now
5422.%
JUN, 7U�1
WYOFLAQUINTA
RNANCEDEPT
RECEIPT -
DATE'BY
D T No
I PECTO
/ „
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 a
Roof Deck i Exhaust Fans
0. K. to Wrap F.A.U.
Framing Compressor 5
Insulation Vents r
Fireplace P.L. Grills t
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior lath
Drywall - Int. Lath
i
f
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel 491'A L
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
Saver Lateral
Pool Cover
Sewer Connection
Encapsulation (/ 10
Gas Piping
Gas Test
Appliances—
+
Final o
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)