0009-001 (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 DATE
Piofessionals Code, and my License is in full force and effect. t
License # Lic. Class Exp. Date
,A
Date % r'� J'� - Sigmture'of Contractor -`
OWNER-BUILDER DECLARATION
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. '
t(.) 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 S`RAT9 FUND Picy No. 046.00-007934
1r
(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 workerscompensation • ovisio�ris of Section 3700 of the Labor
Code, Ial forthwith comply with,those proulslons.
Date: 14/42 Applicant t• ` -
Warni,g: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminalpenalties and civil fines up to $100,000, in
addition to the cost of compensationdamages 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;S fety
for a permit subject to the conditions and restrictions set forth!on his
application. J
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.
BUILDING PERMIT
2�
9 VALUATION $25.100.00
LOT
/1 .�L5ai.{lQ
JOB SITE f.
ADDRESS 4r9.J-':1.t'i�! T.NGLEWOOD
NER, _ —
CASEY R.AWtSLM
55-W6Tam%'W00D
LA, QUDT1'A CA 92253
USE OF PERMIT
I>Mff, AND/OR SPA.
PERMIT#
TRACT
APN
_ I
CONTRACTOR/ DESIGNER/ ENGINEER
STEVE, DODS0.NCONSMUMONWC.
73011 CpUMMY G'I.LlB Mt., BVITE F4
PALM, DESErr Col, 92260
(760)346-40.42 CDL* 1044
POOL $.VA ONLY-ALAIiSttISMARRIERS SMALL st IN PI. ACEAT PRE
PLASTER INSPECTION, POOL EQUIPMM MCIA)SURE IS ATOP WC1,11DET2
IAM THIS PF"IT
POOL .AODIOR SPA
24100.00 LS
:[sS` MgAT= COST OF CC31°7MUC'IalON
2s,$o?,w
PLAN CRWK P114
301 -000-439-31 8'
$16§,03
CONSTRUCTION FEE
101-000-41 9-•iWO
$75$.50
MECHANICAL FER •- POOL
101-000.421-000
M.00
ELECI'IUCA,L M. - PGOL
I01-000-420-000
$43.00
PLITUBIWO ME.- Pool,
101-000-419-000
$27.00 ,.
SM -TOTAL Ct_?WSTl O'Cr lOW AND I?LAN CDECK MIS.
j LF103 PR9-p"D is $0.00
V
TMAL PFIZ1 ' SEES MI NOW $52-2.53
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 author a representatives of this City to enter upon
the above-mentioned propert f ins • ection purposes.
RECEIPT
Signature (Owner/Agenife o 'Date /' • 0,
DATE
DATE FINALED I INSPECTOR
Ulm
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
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
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
oe
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: