0311-150 (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 fyl111orce and effect.
License # Lic. Class Exp. Date
Date ��� Signature of Contractor_
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 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 EXEMPT }a'� Policy No.
3Y:ti
(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 Seciion 3700�of the Labor
Code, Q hall ft ttiwit,�;,c�rl ply with those, rovisionsl/_14 : '
Date: !� i 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 an f oid if
work is not commenced within 180 days from date of issuance efl ch D
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 info rmiation-is —l -
correct. I agree to comply with all City, and State laws relating to the building f
construction, and hereby authorize representatives of this City to enter-up'on—
the above-mentioned property for inspection purposes. 1
Sig ature/(Owner/4ent) % �°' v /-Date
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BUILDING PERMIT PERMIT#
DATE VALUATION LOT ((;� J -� TRACT
el
JOB SITE
ADDRESS.
APN
S4420 AMp1D11\1iqAIXF.®
OWNER Y
CONTRACTOR/DESIGNER/EN (NEER
COV; DEM)OPMENT
LEGACY HOMES
22).4M1'K)GEVtr'001)
47-350AD UM M28
SMrrA ANA, CA
Ste► (arT. NTA CA 92253
(760)564.7820 CBT -Ar' 02063
USE OF PERMIT .
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1.010W.00
PTIRW C 1JIT, NUAAl AWY
PLAN CHECK RE, ) 01.000.439.31 8 $76.05
CONSTRUC•TIO'N FIM 101-000418-000 $1111.00
ELECTRICAL AL TEE -- POOL 101-000-4-20-000 $'+4..5,00
P1..FtMF41Nt!?7%- POOL 1011-000-419-000
_ ^ _ _7 13,x' ,. CONSIMUC.TOM AND PLM,
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RECEIPT
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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
PartyiNall 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
Yd
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer 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
Utility Notice (Perm)
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COVE DEVELOPMENT PLAN. LENCH DESIGN GROUP
P.O. BOX 450
IA QU
-n-FA, CA 92253
OOL
PHONE: (760) 564-11166 FAX: (76D) 5"2627
POOL PLAN ARCHITECTURE & CONSTRUCTION
` UNAUTHORIZED USE WARNING
• _ , " THESE.. DESIGNS ARE THE PROPERTY OF _
LENCH DESIGN GROUP. REPRODUCTION
IN ANY FORM WITHOUT WRITTEN CONSENT
` IS EXPRESSLY PROHIBITED UNAUTHORIZED
• USE EXTENDS TO ORIGINAL'AVD MODIFIED
DERIVATIVE PLANS AND IS APPLICABLE TO
A
INTENTIONAL AND UNINTENTIONAL
, _ •. r INFRINGEMENTS.
.
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` UNAUTHORIZED USE WARNING
• _ , " THESE.. DESIGNS ARE THE PROPERTY OF _
LENCH DESIGN GROUP. REPRODUCTION
IN ANY FORM WITHOUT WRITTEN CONSENT
` IS EXPRESSLY PROHIBITED UNAUTHORIZED
• USE EXTENDS TO ORIGINAL'AVD MODIFIED
DERIVATIVE PLANS AND IS APPLICABLE TO
A
INTENTIONAL AND UNINTENTIONAL
, _ •. r INFRINGEMENTS.
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