9904-020 (RPL)LICENSED CONTRACTOR DECLARATION
U) hereby affirm under penalty of perjury that I am licensed under provisions of
F� hapter 9 (commencing with Section 7000) of Division 3 of the Business and
c i W Protesslorials lode, and my License IS III full fulL u and effect.
C) License # Lic. Class Expate
w 656128 C53 101; if00
Z`te / - Signature of Contractor
—
(Do
�j.
J U C:) OWNER -BUILDER DECLARATION
W WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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
N Date Signature of Owner
ON
0)
a Z WORKER'S COMPENSATION DECLARATION y
C) fr I hereby affirm under penalty of perjury one of the following declarations:
ul p ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U . (,3 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carrier Policy No.
ip
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 are that if I should become
subject to the workers' compensation provisions of ection 3700 of the Labor
3 Co)e, I shall forthwith comply with those pr • slo
ate: Applicant 1//111
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 repr sen)atives of this City to enter upon
the
Zgnature
bove-mentioned property for ins ctiori purposes.
(Owner/Agent) Date 9VM -J
BUILDING PERMIT PERMIT#
DATE 4121" VALUATION $17,10#1.110 LOT TRACT
JOB SITE
ADDRESS 4&4fti TANGELO
M Cb
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
i.(.)t�`'l� 'Mi' �L►C�(IA�J
P' n r Cr�lt1`r1 � T'��P-el.S c'� SPAS
?c* y;�3X 1'71ej s6 TA-NqC-1�0
74-745 JONI T):12t' T, tlA
9.t1 tit t".er tt1 CA. �22S�t
PALM 01 Sk:lt'! C�1 �22A0
[ilk QJ
(760)340-9000 CI30 355
USE OF PERMIT
tWL ANDOR ."4JA
Pi~iCXJSPA, Oiv7_; - ALA:RMWBAftJ3IERS MIST 131E IN PLA.CL AT
PK PLA:i`,i'ER INSPFiCTiON.
�h �l. !11 �AAo4Ji4 ryi� Il 17, 100,00 L SW
ENT114"v4 EDMSTorCONISTUCE10N,
17,101.00
PERA-=1 f FEE SUMMARY
PLAN 6.iUiCKFLkr 10149JU.434-318 StL4,fiS
1-0NR'FR('f( 1't0N FFF, 1(11.(}(1( -419_0011 PI'R�►�`III
i+4r71[al[.17fdl.{ .- 'f P00.1, 101 000 .42.1-000
ELL' ."i10t Al. EEC, -- 101-000-42(1.000 '
I'LLWHING €'"Fj. -- POOL 101400•419-U(i0
81341 ti7 A(, CONt't R1Jrn(-)N ANf) PLAN CIAECK
$407.81
,E -PAID FEFS
1XS8 PR
$0,00
'RY17Ai,M1tA+ IT F1+ KS D'UN NOW
5440.85
rDATE
RECEIPT
DATE
BY i
FINALED
INSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
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
-1-7-
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
-2.5 --
Gas Piping
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
Utility Notice (Perm)