0004-217 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
CO )' Chapter 9 (commencing With Section 7000) of Division 3 of the Business and
04W Professionals Code, and my License is in full force and effect.
=) ch License # Lic. Class — Exp. Date
tidU7
W 518742 C.53, � / NY 1/2(
~o Z Plate i' Signature of Contractor��? f
W 0"7
J U � OWNER -BUILDER DECLARATION
HUJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
fn License Law for the following reason:
Z ( ) 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).
C O I am exempt under Section , B&P.C. for this reason
LON
Date Signature of Owner
O�
d Q WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
K W U compensation, as provided for by Section 3700 of the Labor Code, for the
J Q performance of the work for which this permit is -issued.
Q () �( a)' I have and will maintain workers' compensation insurance, as required by
j Q S6aon 3700 of the Labor Code, for the performance of the work for which this
1LIDI— permit is issued. My workers' compensation insurance carrier & policy no. are:
ct Z
ab 5 c' STATE FUND Policy No.
�a
QJ (This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the work for w ' h this permit is issued,
I shall not employ any person in any manner so a, t be¢6hle subject to the
workers' compensation laws of -Califon and agr th t if I sho 'become
subject to the workers' comensation�ro ''ioirs ' eofiofi 3 0 of the Labor
Code; I s hwjth comply,with those p y to
� Applicant_ -
Warning: Failure to secure Worke s' Compensation cover(w) 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
e 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, indemnity
& 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 l have read this application and state�that the above information is
• correct. I agree to comply with all City, andJSte,laws relating to the building
construction, and hereby'authoriz(repres faiives,)of this City to enter upon
the above-mentioned property for insp ctipn`purp S.
$�ature (Owner/Agent)
�UILDING PERMIT PERMIT#
DATE �12
,0 VALUATION LOT 0004-211 j TRACT
4�1 , S20.OQO.00
JOB SITE APN
ADDRESS 45--3&51?'P' E2 131ROOK, C• IRICIX -
OWNER CONTRACTOR/DESIGNER/ENGINEER
CHAR- Wf8 M,9MCAW POOL COlti t'a'RVICTi{3.9
45-3135 JAM PR00K CIARCLI±. 73960 111
I.,AQC7A4TA CA 92253 PALM J• ESM— Zr CA 92255-•15
('.?60); 40i 2588 CBI:t# 1101
USE OF PERMIT
PCIS?L AMIC li &.44
1`0X71.. & SPA ONLY•A.ARUMBARIZZIf?RS SIIA1. L CE iy Pi. ACE AT
PR&PLASTEI . W8PEC°TI4N,
V.AIXATIaN
214000.00 LS
ES E"TEn MWT OF CONST' UCTIO.N
20,M.00
Pwq CFIES;`K FEE, 101-000-439^318
C0WSTRUCTION V0E 104-000-418-000 $20700
MECHANICAL, PEE -• POOL 101.000-421.000 824:00
ELIV-7RICAL FEE -^ POOL '101-000-420-000 $45.00
PLUMBING FEE -- POOL 101-000.419.000 2210
191TD-T(nAL- C0149i'RUC:'` 10H A14D PLP,A1' C11CCV.
LESS PRE -FAM FF_X--S
$0.00
'] UYA:,1'EW!T FM DVD ; N4VY'
"37155
RECEIPT
DATE
BYf
DATE FINALED
INSPECTOR
�:w
INSPECTIOO N RECO}RD
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
.
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: