0004-083 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm.under.p^ alty of perjury that I'am licensed under provisions,of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Protessionals'Uode, Ahd my License is in full force'and 61TOCf.
License # Lic. Class Exp., Date
27 5'7'05 C-53 0.8
Signature of ContractorT
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.
� ,, Il ave and will maintain workers' compensation insurance, as required by
Se tC ion 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 STATE FWD Policy. No. .044-99-0020325
(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
subject to the"workers' compensation provisions of Section 3,7000 of the Labor
Code, I sha Nforth ith oomply with those' rovr70ns'✓�;�t
Dat• . !Applicant•
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
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 for
�inspec on pur oses L_ /
LS'94ature (Owner/Agent) /4",r��Date /5 ZTJ
r
BUILDING PERMIT
PERMT#
PE.RbMFIX Rii .R.Y -
DATE VALUATION LOT
00( -( TRACT
PL&N CHECK FEZ101.000-439.318
VU 22.0=00
I
101-000-419-000
JOB SITE 1 1
APN
r
$24,00
ADDRESS 45 -IM MJNMF"R00K COTfW
ELECTRICAL ",Z - POOL
101-000.420-000
$45,00
OWNER
CONTRACTOR/DESIGNER/ENGINEER
527100
MM SPRAGUE.
G If. P100L C0NSTIiTJ'Cgi0N
4.5.155 S'[ MN1E"sRBROOK COURT
68.4651'Li� RD,
IEA QUDITA CA 92253
CATIMORAL C1TY CA
2234
922,34-
'i
'760)328.2681 C9
-760)328-2681
t
x
^^
�•,
USE OF PERMIT
itl
POOLAND/Olk SPA
`•'
.POOL & SP?A. ONL•YA.LARMSIBARR.IERS SKMA,
BE IN PLACE AT PRE
PLASTFA IWSPWTION
POOL ANDIOR SPA
12.000.00 LS
XST.l1dAM COST Or, CONS'i'RUM-ON
12.000.00
PE.RbMFIX Rii .R.Y -
PL&N CHECK FEZ101.000-439.318
$87.75
CONSTRUCTION FEE . «
101-000-419-000
$135.00
MECHANICAL, FEE -- POOL
101.000-421.000
$24,00
ELECTRICAL ",Z - POOL
101-000.420-000
$45,00
PLITIVIDING FEE -- Pool,
101-000-419.000
527100
SUB -TOTAL CONSTRUCTION AND PLAN C,k11= $318.75
LESS PRE-PAU) FEW $0.00
y TOTAL r'E T YEF.S 1iUE NOW 5318.7
RECEIPT DATE BY (
f DATE FINALED INSPECTOR
It
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
P
Steel
POOLS - SPAS
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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: