0006-113 (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
Pbfessib7.als Code, and my License is.in full force and effect.
License # Lic. Class Exp. Date
174127 A' ;/ OSf31/2(
Date [:' �"1 } 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: " 1.
( ) 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). a
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.'
f .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 STATE MIO. Policy No. 046-MOPPW34
(This section need not be completed ifthe 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'l should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I,sha.11 .forthwith comply with those provisions.
Date: (•? F,,; :�- APPlicantx* !'�i= ,Z .{; Yr r 1
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-repfeseriiatives of this City to enter upon
the above-mentioned property
�for inspection purposes.
�F iy 3' ; % G
Signature (Owner/Agent)•• Date,6,
�9 -� - BUILDING PERMIT PERMIT#
0F10ts-1 1
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS 57-237 SAM AtWT:'!id►S
OWNER CONTRACTOR / DESIGNER / EN (NEER
8I1 H T*1J,0 &PAGE LLCM4t'.!% 33C-1DSON C:OATS',I RUC71ON WC,
7161 MIANA 73011 COUNTRY CMAJP DR, UU!'t2c F4
RIMBIDE CA 92508 PALM DE T CA 92260
(760)346.4032. Mit 1044
USE OF PERMIT
POOL NDIOR SPA m
POOL. & SPA ONLY - ALAI2I IABARRIERS SHALL .SE )N PLACE AT k;
PR&PLA91 TER MSPECTION, BLOCK WALL FOR FQUJPR4D1T ENCLOSURE
IS Naf INCLUDED IN THIS PRERMIT, I
VALUATION
40,900.06 L3
SUB TO IAL CONSMIXTION AND PLAN CEMCIC I$68:4,40
LEM PRE -PAI 31 NX $0.00
RECEIPT I DATE
1'01; , PkV. VSET FnS DUE NOW
DATE FINALED
c
EST TED C09r O ' CO.Nr ;t ii1171 no ?
40,SOA.00
,PFMW MGU1 Y
.
PLAN CHECK. RE.
101-000.4.39.318
$131,40
CoNs,'ItLIL"` ,ION FM
101-000-419-000
$356.00
MECHANICAL FEE -- POOL
101-000.421.000
$24.00
oucrI2lCAL np, -- POOL
101.090420-000
$45.00
PLUMBING ItE -- POOL
101-000.419-000
$227.00
SUB TO IAL CONSMIXTION AND PLAN CEMCIC I$68:4,40
LEM PRE -PAI 31 NX $0.00
RECEIPT I DATE
1'01; , PkV. VSET FnS DUE NOW
DATE FINALED
INSPECTION RECORD
• OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
S2Backs
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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Dr4in
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
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: