0210-076 (RPL)H
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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 4 Lic. Class Exp. Date
6561 Z8 C53 FIT Z on- I Icre
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.
'1t,� I have and will maintain workers' compensation insurance, as required by
Sid ion 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 COA PENSAT1 Policy No. (0160066) 63-0.14
(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 fpfoVisions of Section 3700 of the Labor
Code, I shall forthwith comply with tt
Date: Applicant-
Warning:
pplicant 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 fog 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 111 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 pursuantto
any permit Issued as a result of this applicaton agrees to,, & shall, inder4ify
& 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 v
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 authpoge representatives of this City to enter upon
the above-mentioned prope 46rjinspectjon purposes
Signature (Owner/Agent) �� ��/' Date; z
PERMIT # t, '
,.BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 3 7fi(D I'.'1teG`.�e1�ffZ1>`sls�N t�G'CJ{'�`
APN
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Cc11�I t.fT.Y C,'kamu'L1 ommimms
°:1Ld C)L�.l�i!,fx1Q%x ca sPiks cn_w, M f co
1535 so. tin lw-U :T, "TM #M
Sf • ! oo AVF_. ,RZ 34
S. ;Ii;k3'I+RtJ1 1 C7 CA 92408
COAC-;'fD:l t A Cit 9 236
f76Ul.�! -9�za 03115 00,1515
�SyAI A�
USE OF PERMIT
POOL 1.1NFN4: R SPA
POOL, SPA, ll..,A.RM;t/BARRIERS SHALL 10 IN PI.A.Clf, [ 'F'R&PL.A.SfZR
MPIit"• 014, I?tjl►I.i -MI-INT MCLOSURR NOT YHOLUl RI)
170M J <WDIOR SRA 1900100 11b,
;JCS'} IX..C11) W6111 Ox} COMMTIL"TiOIN
PRmar' -firER 91.T]>Ms1RY
Pi.f, W CH.WK, ME ]0I.ON-439-31.8 M13.1A►
CONSTRUCTION I'LF; 101-000-418--1100 $198.00
MEECHAWICJ3L FUR -- POOL 101.000-421.400 32J00
IELI;ir"i TICAL PFE -- POOL 101-000-420-000 145.00
PLUMBDIO F'ICZ— POOL 101-000.419-000 $211,00
;,
LENS 31-. 1a'k'AM ]+'M3
$0,00
D
Ypigs DQk:1`+il�
d,
RECEIPT E
BY
DAT FINAL INs ECTOR
CUs
II II y- '�• i rl..� 1 '.•} ry I 1=i ' �•f
i 1
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS _ SPAS
Set Backs
Electric Bond
. d
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Z 44
Final
Gas Piping
PLUMS[ NG 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
Paul Cover
'
Sewer Connection
Encapsulation
'v 5T
Gas Piping
Gas Test
Appliances
Final
p�
Final
Utility Notice (Gas)
CLECT=AL 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)
COMMENTS: