0203-351 (RPL)U)
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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 # Lic. Class Exp. Date
332872 053 ca C)111112C
DateSignature 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.
(�),,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 carrier & policy no. are:
Carrier k)TATS FUND Policy No. 22-P-0006377
(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.
Date• Applicant J .? .r,.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section, 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and
for a permit subject to the conditions and restrictions set forth Lnt
application.
1. Each person upon whose behalf this application is made & each pe
whose request and for whose benefit work is performed under or pur$
any permit issued as a result of this applicaton agrees to, & shall, ind
& 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 issuarice 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.
i 4/
Signature (Owner/Agent) r�''`'' ,;.c -'"t Date ? �'
BUILDING PERMIT PERMIT#
S
DATE VALUATION LOT 02MIA-35 TRACT
JOBSIT90' .r3
APN
ADDRESS
45 -al,% IYRSWr IML, C01N-i_e --J
OWNER
CONTRACTOR / DESIGNER / ENGINEER
.i&t. CI.Ti,73ti;.A1, au.d T
I'RCTIC �#Vii'lmha-NGPOOU
45-150 D.Mwunu. cowu
81 •,5v5 M4t-mOw,I�v1 gLw
LA QVINTA CA 92253
W-110 C4A. 92202
(760)
,347 t3F :t 5"s3 s
USE OF PERMIT
POOL AMWOR, VA
POOL ANTI SPA t -7111,x. Al ,kRh "t 18A3{�:fW SPi.1 1. FSS' 114 sIAC& PR.iOU
t.0 C'R'Y>PSA"1'C.EA. WRF?t.,"1'YEJ 4,
ROOLME:1M fJk'A A00a.00 .I&4
EMULATED COST OFC0M110..0A
SlspI MIR R1yyRY
n.Aiq iiser. , ra 101-00.0-439-318 S140,0
CONSTRUCT VDW PSC 101.0.00 -418 -CICU $216.03
M1`'R_':3�iANICALMZ-• POOL. 101-000.4.21.-000 S24,a
EL PYA TRI CAIL F !q pP0tr 101-(M-420-0-90 W.n
)
1?';AININNO FES •. POL 101.000-419.000
7 t.'
7AR7q-7
�f OP I.AQWM7A K1 .TOTAL OO S`.K.UC'4' OW AM, ?IA11z�3 IrT„ACK
2452.40
7 �}
r'1 AC57 �'CT - - 'I.rJ J`��x..0- C7M ��A5 !
PRE
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b,7 $0,00
•
TOTAL AL Ji Sr1V.i74�6.S� Y' t's. 1S ffVIE 39O
RECEIPT
DATE �^ ���j
ABY
DATE FINALED
INSPECTOR
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.
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
/-"z _ 7 -
Set Backs
Electric Bond
—,/2- - L S
Footings
Main Drain
— y—
Bond Beam
Approval to Cover_
fes_
Equipment Location
_
Underground Electric
Underground Plbg. Test
y_ /a - Z
y —/y . Z
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
— 2- -
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
2
Gas Piping
Gas Test
Appliances
Final
Final
Utility Nott?`e (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: