0008-369 (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
Piufessiunals Code, and Iny License,is In tuii torce and ett2Ct.
License # Lic. Class Exp. Date
574127
D ate Signature of09
Contractor, F
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.
( 0`11 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 F -HO Policy No. 046-00-0007934
(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 persona 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, Io'shall forthwith comply with th. �potiisi ns.X' ,
Date:'W2 S"�`iGi Applicant ,� .®C .�,J ,l -•. w'�
61
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
applicatiori. '�ti, °•"i a;
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 for ins'pectio purposes
✓Signature (Owner/Agent,/,5 6,w�,I/.�`%'� �-` t.� latei3
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0008-369 TRACT
JOB SITE APN
ADDRESS m-9`5o.wgamO W
OWNER CONTRACTOR / DESIGNER / EN (NEER
ICUs it—M21 MWE DODSON COI3MRiT=011 INC.
79.950 TANQL0 73011 COUN-IRR CUU"Ii M. SU11B F4
LA, QITINTA CA 92233 PALM DFSWf CA 92260
(760)346.4032 MVf 1044
USE OF PERMIT
POOL AMIOR SPA
POOL & SPA ONLY ALARMS DARRIMS SHALL HE IN PLACE AT PRE
PLASTER INSPECTION, POOL EQUIPMERT.tNCLOSURE IS WT INCLUDED
IN THIS PERMIT.
FOOLANDIOR SPA 3%433.00LS
"IMKIED cost OF C01W.i1Zi7G"'f ON 3ti2, .00
I'PRM11.' FEE Fillii&hCAW
PLAN CHECK FEE 101-000-439-318 $197.60
CONSTRUCTION FEE 101-000-418-000 $304.00
MECHANICAL FEE -- PMOL 101-000-421-000 $24.00
L+I,fr.CTPJCAL. FEE -- POOL 101-000-420-000 $45.00
PLUMBINO FEE •- POOL 101.000.419.000 $27.00
pis A
SUB -TOTAL CONSI1R (CWOW AND PLAIT ('HW''K $$97,60
LESS PRE -PAID FEF.,S $0.60
AUG 2 5 t029 TOTAKIA108W FUS DIVE ROW
I
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RECEIPT DATE BY DATE FINALED INSPECTOR
er
�V
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION I DATE ( INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Final
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
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
Gas Test
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit -
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice
COMMENTS: