9806-113 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
G'i'*er 9 (commencing with Section 7000) of Division 3 of the Business and DATE
Professionals Code, and my License is in full force and effect. �^^�
License # ' "'` Lic. Class ,Qr `Exp. Date -
���� /✓ ,r ii?11Ut3
LDate�/� Signature of Contrac" for -+' .{
OWNER -BUILDER DEZLARATION
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 rt//� r p 1 f Policy No. t
UN
S.
(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 Califor'ia, andyagree that if I should,become
subject to the workers' compensation provisions oVSection 3700 of th�eL�abor
Cotle,, I shall forthwith comply itKthose provisions{.
-bate"---// Applicant., �7
Warning: Failure to secure Worker ' 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 prZe
y for inspection purpoS S,
ySlgnature (Owner/A L `�� Date`s i
BUILDING PERMIT
?I VALUATION $6,od►Q1:,00 LOT
51-205 AMN LOA VA1.I..9 30
51-540 CISEfv'I-It3WIM D&1
tA'QUfN'TA
USE OF PERMIT
PERMIT #
CONTROL#
yKexa..ps
TRACT 7933
' I APN
CONTRACTOR / DESIGNER / ENGINEER -- -- _- I '
CORONTE:, 0OKS-TRIK *'ciJN
5145,40 EISENHOWER DR.
CA 92253 LA QLfi[r I A. CA 92.253
(760)5644604 x`214, 1.261
POOL �
POOLCMLY, Al.t#RAIWOM. ii MI, +,s':HNI , RV (ia�-iRAVONAL PRIOR TO
POOL ANDD. R ISPA , 6^10.dti LS
EM1tIATC0
COST 01F
C ON I LtUCTIMI
t"EMMU'VER SUMMARY
Pf. Flf 104f CK FEF
I t51 -000 -439 -its
$52.55
(:ONSTRUC'TKYN FEE,
101.-009-4!9-W
W.m
fN4_FOItAN10AL FIX, -- POOL
101-000-112A-000 (.-000
$24,00
t"si`.h;C'Ci'6EYc,e1i. M18 --.POOL
10j-000-420-000
$45.0
RWMBtN(1 t IES -- yr -1011
101 -NO -419-000
527.00
PAJAIAI, COM57RUCMN ANDPLAN CHECK
JUN 16 1998 LESS PRE-PiUD FERS
"4'O'tAL PERMIT FEW% WYE NO
DATE I BY v - I DATE FINALED J INSPECTOR
6.0091000
$2_19.6 5
1410.00
$229.65
INSPECTION RECORD
OPERATION
i
i
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
C
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
ng
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
N
Final
Utility Notice (Perm)