0211-216 (RPL)LICENSED"CONTRACTOR DECLARATION
I hereby affirm under penaltyof perjury that I amlicensedunder 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 p rt
7� ff 051410"
e V .r'
Date Signature of Contractor i
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 STATE. FUND Policy No. 2.29-01,01 W44
(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,land a gee that if I should become
subject to the w rkers' compensa"tion provisions oflSection 370 of the Labor
Code, 'I `shall?foiith,with comply with those provisions_ti.'4_ ...4''"
Date: 1/2 IV Applicant 111__ ........Ay`.-''`" ! 'I(
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, andiState laws-relaimg to the building
construction; and hereby agthorizeArepresen atives of this City to enter upon
the.above-mentioned property for inspection purposes. , ! r
SS gnature (Owner/Agent) �' 't { 4 Date
- = BUILDING .PERMIT -_ PERMIT # - -
e
DATEt =` `= V'ALTUA�'ON LOT_ TRACT
p,''
JOB SITE
ADDRESS 7" 59 NU AVANIN
APN
_
OWNER
CONTRACTOR /DESIGNER REN (NEER
:AAvppDA & CCAiANL
HAL eG/yl.O &a pdCI POOLS S
1'74&341 Lo 1711.13r.0106
35"2 F ONALDSON I .
E'�J fi°1 t CA viz 0
.0 t74~EINY VA,t..i.E'3i CAS 912316
C160)248.6045 MIR 4333
USE OF PERMIT
POM, -WOR SPA
E?tiDUSPA. ALKRAISJ13.cRiR,PIFAS rN fkta .d,:Ite.AT PRE -PLASTER 114SPSIC .
RQUIP, reIC1,00tJRI:NOT t43CUIIZE?.O WEST, 1?F2 ASSM.ED FRA, 1097
UV1FO',,b<. tXMIN. COM §SKS FFR WORK BROUld IN/0 BLDG, PERMIT.
E B DED cogs OF CCNS1RIM%OIT
'1��4Dta�3.faL1
EigI147199
�T 0.7L hi•�' {. Y'
PLAN 4:11=9 PEE 3 01 ^000.439.31 L3 fi1tt�,1p
CONSTR.UCTiON FEE 101-000-418-000 *1162.00
M1TCHAI'1CL"AL EE --'POOL 113-000.421000 $21,00
ELECTRIC/IL )iU, — POOL 101.-000E 420-000 V100
15I.MM01140 VER -- 1100NI.. A01-000-419-000 $27.011
INV 'P-STYG.FiT1c N PC,E 101-000-423-000 $162.00
J;l'" ' `t° T C,099YI71,1'i"TA'ON AAD PLAN 010- ,
$525.30
DEC 0 4 1001 ` aim. F' r.Q:S UE NOW
$525330
CITY OF LA QUINTA '
FINANCE DEPT.
RECEIPT
DATEj
BY it +
DATE FINALED
INSPECTOR
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
Set Backs
Steel
Electric Bond
_
S
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
�•
Underground Plbg. Test
O t/
Fn►al
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
ter Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
S tower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
— -O
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)