0011-245 (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 4, Eicp. Date
574127 ACi3• �� � MIMI.
.
DateSignature of Contractor f -.• r, r
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 .370,0. 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 ST A'�99 AMD 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.. hall forthwith comply with t ose�_P�ovisions.�
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.appjication 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 subjecuperri'mit to cancellation.
I certify that I have tread 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 inspectionpurposes;
Signature. (Owner/Agent) A •'„,f. '^ " ri -Date
PERMIT#
aBUILDING PERMITt�
�" -TRACT
DATE VALUATION OT,
$12,411,00 i
JOB SITE
APN
ADDRESS
55-aS isO�. N HILLS
OWNER ._
CONTRACTOR/DESIGNER/ENGINEER
e
mum J)orssolq �YOW,K�RUC.UOXI WC.
55.586 Bowl EMI J M
7:3011 Cf1tX7141'.!".FiY CLUB D L, 3UM?_ 3r4
ice. QLM4T A. CA 92233
PALM DWIT MY -VA st=+. 92260.
(7'6'0.3=•i6'-$032 _ C!.?Ut iO44
USE OF PERMIT
POOL AND/d3:.��1
a
P0011"11P . REMODEL A.LA.RMSIRAMR.RS MUST BE IN K-ACEAT
RRE-PLASS ER NISP.ECTIC3N, POOL Wsr31is.1' ENT F%FC3.C?StXRF Is NOT
@31C1~Iii��i3.
POOL .Nf,Atl.I OR SPA IZ400,00 M
tA�7hJL��Md.l;1L'dL� con 4..y `i`lJ3�r4J �.�t.W,1.-JL8o �
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P i CHEC': 9EE 01.-t400A.39.1,18 191.60
C.'ONSTItU ' TION 140, 101-000.41(4-000 0144,00
MECHANICAL, FEE •- POOL. '- .1,01400411.-.00t1
Rl.f:YvrpudAL g R -u PW ` : t0l 000-a1�S?-Q4bi} id9.1�
Pg:(3Zl�MO PFP-.'-1s004• _ 101 -M -4t -94"M NUO
30B.`i`C rAL C 0HUR C,tCTION.ANDP%>,.AMC'.�t�fc'
$3:33.60
RECEIPT
DATE t
BY
DATE FINALED
INSPECTOR
,/
I
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
OX 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
dj)
Unde est
O
Final'
as Piping
PLUMBING APPROVALS
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
kLI
Gas Piping
Gas Test
Appliances
Final
4
COMMENTS:
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)