0104-299 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
t -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 w Exp. Date /
f
Signature of Contractor -2".
OWNER -BUILDER DECLARATION
I hereby affirm underpenalty 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.
( fj I have and will maintain workers' compensation insurance, as required by
S ciion 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:
Cartier Policy No.
(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,0,
I shall not employ any person in any manner so as to become subject'to the i
workers' compensation laws of California', and agree that if I' sh'ouldAbecomef
subject to the workers' compensation provisions ofi Seeti6n'3700 gf the Labor
Code,, Ishall.forthwith comply with those provisions! Ir ;
Date: j•t-, i Applicant'---
Warning:;Failure to secure Workers' C81 pensatition coverage is urylawful and
shall subject an employer to criminal penall es -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 'representativeseo, 1- its^City to enter upon
the above-mentionedproperty for inspection pp�rpofses.l Jr
jSignature (Owner/Agent) r"f"l( Date 12i. � : r
- BUILDING PERMIT PERMIT//
DATE VALUATION LOT W04 -2W TRACT e
AV
JOB SITE - ' i
APN
ADDRESS
43-00 ` 7 Ai7&VS COURT
OWNER
CONTRACTOR / DESIGNER / ENG INEER
43-63+;':C/ T21118 CSC URY
82-762 CTIARLE AXI AYX
:IyAQIY TA CA 92253
D 10 r"'" CA 92255
Ci6g)275.6403 CB14 1,60+4
`
I
USE OF PERMIT
L Alm/o C SPA.
POOIA;SPA ONLY • .A:LAFTIY 3MAPIRIERS MU 3' 1SL IN PLACE A'I'
PREPL. STIRR MVQ..CTION, POOL TSN 14KYRRI? IS NOT INCLii3G►w
i
POO ., AP1NOR SPA . :v00,00 L
XSd:1.I4t1AW3 C;9�' q41+' C;CT�Fb�J"CB(7I'1C
liJ�3.0£3
i�pp��Q`•..�a99����{{°g1�'//Vy���pp.�yyi++�+yy�'i�i�i�cy
101-000439-3'18 111.415 q Q
t.C, NVi'3IUCT1014 FRE 101-00.418-000 $171.00
.MS CHANICAL nZ .., POOL 101.000-421-000 $24.00
W,:";yt;TRICAL F49 - POOL 101-000-420-000 $45.00
1'1.,BTIa BIAIOFEE, •• POOL 103-M110-419-000 $29,00
SUB -TOTAL C01,l`jrRUC"I10 1!ND PLA14 C }XIK
$378.15
XX33 PRE-PATI)MS
RECEIPT
DATE I
BY .
DATE FINALED
INSPECTOR
4-� !.. I(c .
�
t
INSPECTION RECORD
r
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
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
PIJ�
—Or
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)
't