0310-191 (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 Exp: Date
72f4796 C;53 C61 U35 10131/2(
Date 4. 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:
( j 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 carver & policy no. are:
Carry STATE. FUND Policy No. 1683412-03
(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 those provisions., • ;
D e: 0 77 a ; 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 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 property for inspection purposes.
�Sign'ature (Owner/Agent )/�'- %'.�-� -~ ` -'%r r Date Ie
BUILDINGOPEFhAIT PERMIT#�
DATE VALUATION SW
(� f� C►LOT TRACT
SdRI,�a 0 .00
J/i, '' :; . 1;
JOB SITE
APN
ADDRESS 4.9-200 FD)<! BIBIE DMV.L
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
bRTC GISLI;
JeLflfl}�I TF SNR.INIGS
45^.G0017EMBIEMME
71509 SAN 1301?C30NIO
LA Crum -A CA 92253
RAi<dCEIO M1ftAOF, CA 92270
(760)341.2336 CEUf ?486
USE OF PERMIT
POOL ANIVOR BPA
R'OOL&IIA,, OAS LINE TO FUTURE BEIQ dG: BAR- ALARM:JRIi RRIERS
;,HALL RX RJ P.I.ACE AT PRE- PLA11'TFR INSPCETION. E1QvV1PMFN,�71'_
ENCLOSURE NOT INCLUDEDI �
POOL AND/OR SPA U3
'CT 22 2,'3 G
"I'DI ATIM COSI' OFr COA1IMION
20;{}g1i X01
PERE :r,W E ST,M. MARY
PLAN CHECK FEE 101.000-439.318 $134,55
CONSTRUCT1021 MF., 101-000-418-000 520700
MECHANICAL FEE -- POOL 101 X0.421-004 $24,00
ZLEC'TRICAL IFFE -- POOL i 01-000-420-000 V5.00
PLUMBING FEE -• Pool, 101.-000-d 19-000 sinoo
910121340TAL CONMUC"TION A2d1,7 MAM CHI?CK
LESS PRE-PAU) FRED
3'0fAI, PEIL11W If`FES DUE NOW
4437 o45
RECEIPT
DATEBY
D N yyy
1 PECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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 a SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
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 I Al
COMMENTS.
:-
Final
Utilfty 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)
V
+18" spa with Stacked Quartzite Sp
SPA 7' x 7'
fl)d irk j� J.�I — i' , `_. • �� � / a!•, >v��'"-
�. inti-, qy r ,� I o� •4"� � j��,, -`�*`
4'9
400
• 'SMS1619 0
EQUIPMENT 100 •
LOCATION US •
• •
ERIC GISE
45-200 Debbie Drive
La Quinta, CA 92253
= Umbrella Sleeve (
CITY OF t, quiNTA A RE -INSPECTION FEE
BUILDING & SAFETY DEPT' 'v�tILL BE CHARGED IFTHE
APPROVED PLANS AND JOB CARE AR
FOR CONSTRUCTION THE SITE FOR A SC
INSPECTION.
.NO EXCEPTIONS!
DATE
WN V