0307-131 (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
Date `I Fr, Signature of Contractor A
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).
( ) 1, 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 'R-YsVb'iFT Policy No.
(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 3700 of the Labor
Code, I shall forthwith comply with those' provisions. 1p"
� r
date: , "' Applicant—`-
�r•
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 inspection purposes.
(Signature (Owner/Agent) r1 % . -., Date
PERMIT #
BUILDING PERMIT
r �`
DATE = VALUATION LOT TnACT
JOB SITE
ADDRESS �}.�a44.9Y.Itrc<':i►# C�Odl,d';
APN -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
TDAU M0 OPT
45-21;; !JUN NROOK + `k-Z"RT
AVE9113A2+fi.+�i"13'�Z<'�
CA 922a3LWrA
�S223'3
�� .�;y
USE OF PERMIT
POOL J"I)fOR 141wptt
�. �.L.Nt+ ,, dS.Y L,� it.,t:�„�s .i..r•.7i9•LYy'J�j tyi.ruv,iu+.�+e tiiu:t e.ti.� ai- rx�t..:.ti .
IN PIACF AT 'PUT-y3,A`,!"ER hq%3P.PC TIOE;, F.,OLfrj?M 14'T &ie,`i.03IRi+..aOt"
r�r.:l"c�rai�i3
`SPA 1��;�: �� U;
����.�`AIKI COST OF C�0115�'.Fi'Of,'.'1',C"sfI
.�1 1 MFdi:£!�A '
n��►�y, �r�},�y�yy�
SYArS•.tA.fi.i A/d7.rE 1ArM., tZ'UV( Y
PlIM41 G.HFCX FES, l 01 .100-439.31Is S�;lS.3G
Cf:SN5'fTlf CT'fON M., i01 -.0000 -410 -(VO I)t�2.ili!
MMHAI C"FESE... FrXf L 161-Ui` -421-O K' E24.4A
Ei.Zt.:'d Pj U, PEE - 1,0<31, ;
;11•,Ofi+t8510 FEE -- ss•,t:,.. 101.000-31 9..0r" $27,00
D .
JUS 14 2 3J 0 3
FINAY.. �+ PT.
SUTV s1':('&IC-011TS!'lt.[Ti.,Cdfi?N•J1'A 5 PZ."cmcv.
�:36a36
��7rJ.RfSJ d ikJ1'F.i'Y.t.G �.l 3'. k�. T,� WS3 NOW
RECEIPT
DTEBY
DATE FINALED
INSPECTOR
y
01
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
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
0. K. for Finish Plaster
Sew 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
Wity Notice (Perm)
CITY -OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS -
PERMIT NUMBER
OWNER BUILDER -.--
This form shall be posted on'the job with the -Building Inspection Card at all times it a consaicuous
place: Only persons appearing on this list or, their, employees
are authorized to work
on this job. Any changes to this list must be approved by
the Building Division prior-to'cornmencement
of work. Failure to comply will result in•a stoppage of
work'and/or the voidance
of building permit. • For -each applicable trade, all information requested below must be completed
by applicant: "On File" is not an acceptable response. h
'
Trada.:
......... .::;....
...........:......o........................::
..._.._.............
:...C.
..:..W
t�on.Insuranceaa.sl orkes;
But,
_...s.s...L_i
:-e.....
..n..s.e.....:::
an Name
ssi 'cation
Classification
sa Number
License
Exp. .Date
rrer Naime
Ca
P lic Number
'License mb-r
e Nu
Ex . Da
teExPDateom
(e.g..B jC
1xxxxxx1
(xu xz xx1
1e.9. Ste Funda1C mP1
1FormatVarie
s1
1xx xx`A
/xx1e.
xxxx1
xx xx xx
1ta
EARTHWORK,I..C.;�:;::�
�!'L�-. tn�1 � � A-
A-
'o a k 0`7 -.
-.12 03
I
S a f� •r�� �
of vs / g 03
D q
7 �
O
CONt�.RET.1.: 1..
P `_�- >,�..�.�:.-ld.�c.d �E
•C-
6
� � � ZZ
o
STA ! L
�.i
o� b a
6 _
6 V
/
y
NGs:: :5>:
FRAMI.. .:L..C.. l .
STRUC:TS7EEL:;��::�.;:..:.:
Cao C� v
G S
1
�- �v� •1cJ r
c _
b l I G J� D�'
- D
0 6 8
5 3-
MASONRY';IC::..::1.:.:::.;:::.:;:.::.;::;.
C o -
_ S 3
7 /5 3 r
7/ L
- S�r�-� �N-H
lio
O G
•� 0 3
PLUMBIN(i.IC::»:>;:;�::;::>::;>,,.;>;:;:.
G i,.> �...�n �, �
C .�3
�1
� 3 7
1. o
�.. s-�►�-1•--� _
r b 6 � 6 0 v
o
t3
0
7 31
1 J O
LATHPLASTER.(C.; 3 I:; ..
5 �-1-+rr7
.T
-
G -. 5
_
1 O /
i� ` p.
5�9-- _�i,.� . __
0 U
o f
.� 0.2 S� .
C
0
3
DRYWA.:::.::�.:.;:.:.;::1..;::.>:.;:.;:.;:.;:.;:;::
_zz
'
300 �0 -
O $)-O 3
-
db p
9-i� •O
"`p'
_. . .
f
ELEC?RICA..::�:..::.:;i'
f
-
G AV' �4-� `�1 � �.b.•,�, �+-,
l
_ S
5 •Z � `�
I L.
0�
�- T
5 �
- 2
7 � b �
o J
.
Y 3 r
r 0
0
t�J
.
ROOF G..1. 1 » .
SHEET METAL:.IC.::.....1;::.......
FLD.O.ING.1 1.::.........
�
-
OLAZINa-
•
:.
INSULATlO C 2 ::.
-_
PAINTING. fC`=331:>
CERAMIC<;TILE:: C=64)
1 ::.:.!::::::.:...:::::::::..
3
BI E7S< C=6
•
1
CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS PERMIT NUMBER OWNER BUILDER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "Un File" is not an acceptable response.
e
1. ' 1'
EMICAL
e
6" raise beam
IS' raised spa
8'-0"
3tr notuaral boulders
stack qurtzite'-
- TRRMpp1-IN E `
K., pebble finish m
6,0„ 3,6„ °
.i -
stucco out side 30'-0" ,
4" bench natual grey broom
• to ma h house .
auto fill
skimmer - vac line
existing concrete
time clock y tile tbd by owner
and switchs
400,000 btu hayward heater" pebble tbd by owner
.3,020 cartridge hayward=
S 2hp_hayward northstar
access
aqua rite (salt, system) •
bobcat
s fill low area H0-A E OF DAN & 'CRIS M
at excavation remove sod
45=215 SUNBROOK LN.
V
LA QUINTA, CA.
,r y
tj
3s g��