9908-082 (RPL)�.., LICENSED CONTRACTOR DECLARATION
eFeby 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 Lice.nse'is in full force and effect.
License # Lid. ClassExp.,Qate,
r Z.
.Y, •�' a
/ate a•�" "'� Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that) amexempt from the Contractor's
License Law for the following reason:.
as owner of the property, or my employees with wages, as. their sole
compensation, will do.the work, and the structure:is not,interided.or.offered-for
sale (Sec.. 7044, Business & Professionals. Code).
( ) 1,. as owner of the property, .am exclusively contracting with licensed
contractors to ' construct the project (Sec: 7044,' Business .& Professionals
Code).
O 1 am exempt under Section 88P.C. for this reason'
Date Signature of -Owner
WORKER'S COMPENSATION DECLARATION
l 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 Policy No.
S ATE %Bit!1D.
(This section need not be completed if the permit valuation; is for.1$100.00 or less).
t O I certify that in the performance of the'work forwhich this: permit is issued,
' yl shall not employ any person in any manner so as to become subject to the
workers' compensation laws of CalifdrniW and agree'tliafl-vl should become
esubsect to the workers' compensation provisi6ns of Sectiori3700 of.the Labor
Pode, Pshall.forthwi$h comply with th s'e p�visions-/
yDate: �fl` fir •` f .Applicant .0 ae - /'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject.an employer to criminal penalties and civil'fines. up•to'$100,000, in
addition to the cost of compensation, damages as provided for in Section.3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is.hereby made to the Director of Building and. Safety
for. a permit subject, to the conditions' and restrictions set forth on. his
application. .
1. Each person upon 'whose behalf this application is made & "each person at
Whose request and for'whose benefit work.is performed under or.pursuant to
any permit issued_as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit' issued as a result of this application becomes. null and void if
work is not. commenced within 180. days from date 'of issuance of such
d' permit, or cessation.of work for•180 days will subject permit•to"cancellation.
I certify that I have read this application and'state that'the above information is
correct.I agree to comply with all City, and.State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fo. reinspection.purposes.
vSignature, (Owner/Ag 1). "`'~^—a - `" bate
PERMIT .#
BUILDING PERMIT
DATE %%' A VALUATIONLOT I.TRACT,'.
JOB SITE -79-3".
APN _
ADDRESS:
OWNER
CONTRACTOR/DESIGNER/ENGINEER
FU7' "C,;tAPS LL -C:
i TA .wyvSTtb'mrmv , ik.
P BOX 810
A425 E. L NIMSITY DRIVE
TrftQ�Tff`IT'A �!�. 92253,::
[�Hf.DFL`3 �5' 7 85034
(60,2)2'T7-16_56 CBL# 11990
USE OF PERMIT
1100L AN01t: K SPA
P001. & SPA 01MLY - ALAF.1ASISARItt'FRS—;. �LL 'itS. IN PLACF3 .FX
PR's. -::tip TIER IMMMON
POOL AYdi)JOR SPA L3
F.S';I'MF11b E D CC$wr OF CONSTRUCTION
PEMIT.I': EE. SUMMARY
PT �f� d.`IiSObt. �'i� B t3.P.-�tli!•�t�9-31fe .. �7�,.o.1S
CONS'T'IRIXTIONFF-6 S117,00
N -MC iANICr , Fri -- 1730L I01 -000-421-061D $110,00
$45.00
01.000-41f):Wa S27M
SU.S-TMAL C0.NSTRUP 110N :AND :PLAN CH :CK
vzrya
DESS PRE-PAJD PEES
S0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
10 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 Wail 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
f
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 1
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
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)