0210-031 (RPL)N_ rA
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LICENSED CONTRACTOR DECLARATION '
I hereby affirm under penalty of perjury that 1'6m 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
d^'
Date 656128 Signature of Coniracto�'"S`�� liif:�tfOa
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.
�() 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.
'q- ATL �r[3 1? h1 1 (14 1) 4;
'q- 1
,(This'section need no be com 'ITted if the permit valuation Is forq'10 & or less).
=) 1f 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 agr a that if I should become
subject to the workeW. com; em ation rovi I ns cif lection 3700 of the Labor
P` A� c ph � ; r•
Cody s1all�f Ahwith compl�-AA`Mhos 6� islons.
Date: Applicant
Warning:, Failure to secure Workers' Compensation coverage is unlawful and
shall subjectan employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to�
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to. comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pro erty for inspection purposes.
���
Signature (Owner/Agent) Date
�-- - `i__�BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
r!t- 1 ,C)?-' ' 0210 -VAI
JOB SITE u`yiaU��$�.
APN
ADDRESS
OWNER 81,640 `I.A1kITiROIN DRI'biit:
CONTRACTOR/ DESIGNER/ ENGINEER _
'f'C:.C,..L M0`1uffu.; YRC!
CALW, 1A P001,01 & :SPASS (':t I' MAST t::0.
74-5 P23 1-MMY Lmr-.
moi• 100 AV UE 54
.PALM LW111J „; ,, 57w 60
C01V7�1�.L CA 92236
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(7160)39$-,9221, C.'4 9 010355
USE OF PERMIT .
Pf3MAND/0rt EPA
POiI,SPA3dQ(A1SZ'21-584993), MRSPIT (496 AWU,� 20
U. 4' yyLOC.X FC.U, C% YYfiAVV1M A.nDRNS1MAi11.3 WALL RE
4 Ff, MALL 20.00 L
POOL .AND/OR SP 3;i ft), 00 115
PLAN O FII X FZ 101.000.439.318
CONSTRUCTION FEE 101-000-418-000
MECHANICAL 1'`ZZ -- POOL 101 -000421 -000 'EX00
St=- TRICAiI. FrZ� POOL 101-0:)0,420-000
P1StJMIM1t:^FfiFIF,..: POOI,r 101-000-419.000
SUB-;['C�TAX, c�L3l '..7y:AWr10K AND 1`'UR C. MK
D l; LESS PRE -.P 1MV
$4196.95 '
$0.00
CACI 0 0 ZZ
CITY 0 "LA QUINTA
RECEIPT ! BY DAT N LE INSPE
T R
VIA
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
y
Footings
Main Drain
_ _
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Gas Test
Appliances
Final
D
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)
COMMENTS:
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