9804-113 (RPL)LICENSED CONTRACTOR DECLARATION
I,hereby`affirm under penalty of perjury that I am licensed under provisions of
°C,Wter 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
�/ * -5 s.
UDate ��� ! ``)� Signature of Cont actor �f 1_<_2. �.x
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&RC. 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.
(This section eed not be completed if the permit valuation i044-97-0020325
�for $100 0 orrlless).
( ) 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
subject to the wprkers' compensation provisions - Section 3700 of the Labor
Code, �l shall f rthwith comply with th . se provision's'?... = ' `�-'r
Dater� .9 "AES Applicant ��^a..t� r
Warng:`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.
i4
n
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
conshe" truction, and hereby authorize representatives this City to enter upon
tabove-mentioned property for inspection purposes.
'Signature (Owner/Agent).'-" F`'f" —Date
BUILDING PERMIT
DATE r` !< VALUATION LOT
JOB SITE,
7 1 ADDRESS
OWNER
PERMIT #
9U4_113 _ TRACT
APN
I ICONTRACTOR / DESIGNER /ENGINEER
ROGER
tSAI(E1.;LE�Ny iitE�RGER & ASSOC.,
LA QLWfA CA 142253
USE OF PERMIT
CONTROL# "
7479
ts. H: POOL CONSTRIXTfON
69-465 PEKEZ RD.
CATHEDRAL CITY CA 922.34
(760)32&2681 C,BL# 69.
POOLISPA ONLY, ALAPMISAPRIERS ARE TO BE OPERA'TIONAT PRICiR
TO EN-GAP/PRE-PLASTFR IN'%PFXTION.
POOH`, ANVOIR SPA 14,300.00 LS
CSTI1kTXCED CONT Or COINS° &iiTCT. ON
PERMIT FEE SUMMARY
PLAN SCK FFE 101.-000-439-319 $105.:30
CONSTRUCMNFEE 101-00041$-000 _ $162.00
VWCHANICAL FSE -- POOL .-101 =000-421-000 ' $24.00
ELECTRICAL AM --P061, 101-000-420-000 $45.00
PLUfvMrNG PEE --'POOL 101-000-419-000 527,00
1?A6u11?0Ii_AL CON STT UGRON AND PLAN- CMC1S. $363.30-
APR '21. LESS PRE -PAID FEES
1999
TOTAL PCRNIrr FELE DUE NOW S363-30.
ITY ®F Q.U1N ;
RECEIPT DATE s' i f1' eY`. DATE FINALED INSPECTOR
44
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
i 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
i Electric Bond
A3'
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
I Underground Electric
Underground Plbg. Test
Final
I 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
i Pool Cover
Sewer Connection
# Encapsulation
_
- —
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Ko 1097e, tos-mtIvA At( QTS ZO
oL S
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
0,,�d 7
BUILDING A,
SAI -ET �DI '
� M RTMENT
CC?NDJTIO, ,;A L
ACCEPTE6,FOFj C:�.' f;Cit44 87'
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RCI 1 A II[nT A Ml I. nrm n
100
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SCALE : 1/16"=1'-0"
•
I.
100
r
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O
SCALE : 1/16"=1'-0"