0206-129 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I amilicensed 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
6561.28 C531 -11C C-8 10/3/102
.,I
Date ; ° 4 023ignature of Contractor f?
OWNER -BUILDER DECLAI ATION
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.
(,A.1, 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 a'rOMPRNBA I Policy No. 0460006168.01
BUILDING PERMIT PERMIT# t
o2'ra�•x�.
DATE "`'-1LUATION o
q �y LOT' TRACT
�` Yy7'Vid
JOB SITE F APN
ADDRESS `•16Y�d..rab 1�rf S:Ai1t�+ ^
OWNER \: CONTRACTOR / DESIGNER / EN &NEER
M, T'lM2T D:lR YTn6: X49,,E.A1^ K a 4. a CA.LLC C)PUB. A P001Z SPAS t,'`.MP 11024 (Xt
LkQT0X,rA, C.r$ 9225.3` P. A 1. irt DF. A LAW:i USI
f,7�Lt�a�1tJ��r:)QEt G':�� Q�35S
USE OF PERMIT
P0OJ, MDIOR SPA
(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 thosgprovisions.
Date: Applicant ,! . A-
Warnin' g Failure to secure Workers' Comp n a on overage 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 undef of 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 omploy "es
2. Any permit issued as a result of this application becomes null andKiOi.n'
work is not commenced within 180 days from date of issuance opermit, or cessation of work for 180 days will subject permit to canceI certify that I have read this application and state that the above informcorrect. I agree to comply with all City, and State laws relating to the bconstruction, and hereby authorize representatives of this City to enter
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) A/111 Date
POOL, Sats, 838 (ANSI Z2I 334995 WATER M'Pi. RRA iia L.R.
Y pLOOX WYVL.I, CITYSTANDARD AL ft3� �E3 a �}iA6,•L �' Iii
PLACE AT PRE -PLASTER LBSPECTIOW.
5 PT, WALL
VALLI,ATTO 8
10.00 L.I.1?
I4,m:t?0 u4
:ll`i�'.1 AIV) COST OF Cd9N I'RUC°: ON
PLTWT F'X1@ SUM4:+4bRY
PL_ANi CHIRCKFEF 101.000.4,19,.18 $534,13
C'OICT1'RUCTIOM ME 101-000418-000 $207.00
XW-ki:&1NICAL M .- POOL 101-000.421.000 TROD -
t?.LW,TIrICAL F&E ..; POOL 101-000-420-000 U5. 0
PL1JMI;sINO FRE -- POOL, 101.000.419.000 MIN
xf
• 1 -
SUB -TOTAL i'"ONMWE.iMON AM) PLAN C'E:MM'
S RIM -PAW 1'�.f 33
,s
ORA
DATE I BY I DATE FINA�LLEED 2
19,,� WM
$41?.$5
$0,00
$43 7_5%5
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.
s Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
!
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam Z
I Approval to Cover
Equipment Location
�— p
Underground Electric
J p�
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
j
Gas Test
Electric Final
Waste Lines
Heater Final
iter Piping
Plumbing Final
T
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
2
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)
COMMENTS:
,