0312-044 (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
6.56128 C5? I -11C C`
Date 1, k' L 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).
( ) 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 STATE r;nidlP3;`NSP I'1 Policy No.
040.6163- 103
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions
Date: P s /-I ll� Applicant Pf / - Y1
Warning: Failure to secure Workers' Compensation coverage is unlawful and. t
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`by of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
t 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 Fepresentatives of this City to enter. upon;,
the above-mentioned property for Inspeetori:purposes.
Date
Signature (Owner/Agent)
BVILDI`NG.PERMIT PERMIT#
O
DATE � VALUATION LOT 031�, o-'Qa�� TRACT
JOB SITE
APN
ADDRESS 81•-2..A:3 SWRN OCK ULLS
^
OWNER
CONTRACTOR /DESIGNER / ENGINEER
ASHBR00K.. DE1►`KLOPMW1 1 CO1vrPM Y
CALTF 0RNIA., POOLS 9FAS (POP MAIN CC
51-40 AAYMMA EX-C)NAS
.86-100 A.VESUR 54
C'"1.,SDAD 4CA 92CW ,,,
COACI-MI.1:.A. CA 92236
= .
, (766)398.92.22 c1lu W355
USE OF PERMIT
FOOL AMWOR SRK
POOL 311A. F 3Q (ANSI x21.M-1995) .>9.LAR.IASMARRIERS SIiALL BE:
IN tIL&CE AT PRE-PLASTM IN4Pf.;tM(YR. EQUIPIu MiT P0401A. SURF, NOT
INCLUDED
POOLANMP SM i0,(IvoieO LIS
'E'.'� TED Msr Or CORM:UC'ION
2b3e�K .�13
PLAN CHEC'IP ME, 101.000.439-315 $134.55
C014Sa'RUCTION FEE 101-000-418-000 5207,00
MECHANICAL FEE -- POOL 101-000.421.000 $24.09
ELECTRICAL FEE — .POOL 101-000-420•-000 $45.00
PLUMBINO IfElp =- Poon, 103.000-419.000 $27,00
SUB -'TOTAL CONMUCTION / ITO FLAB' C:' 1EC'IC
1iG 17.55
I689 PPD+PAM;[+.I
$0.00
I'0'CIi lWTrMS: UE1'a0WA37.DEC.08003
55
tFINANCe
ITY OF LA QUINTA
DEPT.
RECEIPT
DATE.
BY
DATE FINALED
INSPECTOR
RP
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
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
lWater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
O.K for Finish Plaster
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: