0005-169 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1• -am licensed under provisions of
H:Chapter 9 (commencing. with Section 7000) of Division 3 of the Business and
N
(Xi
°�" �S'rofessionals Code, and my License is in full force and effect.
S ch License # Lic. Class / ' Exp. Date
r I LU C5
Z � L a1 to - i ' �r `'S4ignature of Contr ctor
tp 0( i
J U C) [
OWNER-BUIL/ DECLARATION 1!
HLLL! t` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CD 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•`) () I am exempt under Section B&RC. for this reason
LO
N Date Signature of Owner
ON
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U-0_ Q WORKER'S COMPENSATION DECLARATION
o � I hereby affirm under penalty of perjury one of the following declarations:
H0 (-) 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3,700 of the Labor Code, for the
m � Qperformance of the workkfor which this permit is issued.
Q U ( ) 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code; for the performance of the work for which this
D: L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 8TATE FUND Policy No.
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J (This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of theywork for which this permit is issued,
I shall not employ any person in any*madner so as to become subject to the
workers' compensation laws of Califor ra, and a ee th t if I should become
sub' t to the workers' compen�t&ory ro f1s, Seg#Pon 3700 of the Labor
de, I fplttbwit comply with li�ose .ll
Date: �- Applica(i
Warning: Failure to secu % orkers' Compensation cover .e'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
Zconstruct; and hereby authorize repre, enativekof this City to enter upon
he ab e -mentioned property mop nsp�ec 'pure es.
Si nature (Owner/Aa nt (- `( Date)
"� G1<� BUILDING PERMIT PERMIWC-6-
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69
DATE VALUATION LOT TRACT
�;s �,llli1,41i1
JOB SITE
APN
ADDRESS 45+-4€I0 DEE1WROOK CIRC J+'
- -
OWNER
CONTRACTOR / DESIGNER / EN &NEER
"NN•;3A rff
SURAW,F100L.9
45.480DERMBROOK C. RC11L
F',O, BOX 835
L,k QtT,[t`f:rA CA 9725;
PAJ,U DMM E t;c CA 92261
(616)508,4014 C131,ff 529
USE OF PERMIT
BOOL A>)TWOR S1:'A
POOL d". SPA UR1f Y-A1.A121+Hfl.r.At2.11sFS SHALL BEINPL,'�CF'. ATPRY,
PI,A,'jTF, INSPECTION, POOL. EQUIPMFN iT 9W01_4)8[IAF )S 1401• NOLUDRD
fN T1.118 PEP. 11T
POOL, .AND/0.11 '1PA I k I tt0. 00 L•S .
ESfMN11FD CONT OF CON4, r11RU IC11TON
PL.AA. G1•II+CK rEE 101-000-439-318 $117.0101
00144 T RE. (70014 FFS 101-00U-416-030 $180.00
MECi-IAIACAL IEE -- P001. 101.000-421-000 5..24.00
L.L1i:'C."1'R1CAI,129Y, -- POOL 101-000-x120-000 &1y,U0
PLUN1131NO VE9 -- POOL 10).0010.419-1300 $31.07
,
SUIS-TOTA.T., CC)NSTRUMCW AND PI -1141 C HT_'CY.,.
$393.00
..U.30 PRE%-111AZ_U Y-'.9SS
$a 00
T OYAT, PHOT 1W.8 DCT ' -NOW
i g IA)
fir'•
RECEIPT
DATE
BY DTE
FINALED
INSPECTOR,
�,
! SF'PCCTIO�J RECOO F'.�}
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
B LOCKWALL APPROVALS
POOLS - SPAS
Steel
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
oe
Poe
Final I.
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: