0212-059 (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
MC r-24 1.Wg3:1104
JPate a :�� Signature of 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 6wn6Ft,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
'Scion 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 STA, 'I: C0 bQP1s"AIB.AT1 Policy No. 0400610-0
(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
•' ,subjeof.fo;athe;workers' compensation provisions of Section 3700 of the Labor
Cod ),shall'forthwith comply with tNse provisio S.
=Date:' -'f1' ;*v'^ as ADDlicant �/ ldj,
Warning:`Failure'to°secure Workers' Compen�ion coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100;000, in
addition fo the cost of compensation, dainages 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 o.r pursuant to
any permit Issued as a result of this appllcaton 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.] 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 inspection purposes.
g
Ignature (Owner/Agent) Date JB ram
BUILD NGRERMIT
DATE VALUATION , t2lt(MWLOT
JOB SITE!
ADDRESS
� n
OWNER
PALM IDEW'T° C.A 922,60
USE OF PERMIT
POOL AND/OR VA
PERMIT #
t�Y2• 6,
TRACT
APN
CONTRApCyTO�R• / DESIGNER /�*(
E+�N61N'EERp SPAS
(4 { }
MAX CIO. ZP
C11 ACTO:I:lik CAS, • 52236
(760)398.9222 ClUl 00355
OOL, SPA, 0BQ(AN3I Z31-5941995), .15 L.F. 4' S RC1: WALL,
CITY STANDAM ALMIM&BARRUERS IN PLACE XTP1?F P1,,..MTZR
POOL AI+1DIOR SPA
11
13100 LF
30,440,00 LS
ESMU ED COST OF COX,= Walaom
f r
6
FMOU NER 903WMA Y
PLM G'1MIX FEE
101.000.4394318
51440
d3NSTRUCTW?4 FEM
101-000-4M000
$ 1G.f30
MECR 14ICA L FEV, -- POOL
1.01-000-4%1-000
$24M
ELECTRIC M, FES — POOL
101-000-420-000
$45.00
PLLtMBIM0 PT -- POOL
101.OIDC-419.000
VIM,
SUB-$i7"rAL C'ON,%*R0Q`110X AND PI.:.EL1+1t:W?,F,"X S452.40
DEC
z Of LA QUINTO`
IE EIPT f:1% BY r DATE FIN ED 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings D3 d
Main Drain
Bond Beam lj
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
Gas Piping
Pool Cover
Encapsulation A!�!W6024-s,5
Gas Test
Appliances
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
1.161ity Notice (Perm)
Final
COMMENTS: