9901-142 (RPL)61
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
�� 6i -%5 i u 11130/00
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at Signature of Contract r
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 theirple
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.
(,r1 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 Policy No.
STA'1T7='i'Jihn fzffblil5 4
(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 a ee th.j'+f I should become
subject to the workers' compensAtion p[ovisions of ection 3 AA-pf the Labor
Cede, all f with comply wit, oseiipr visions.
tDate: � Applica
Warning: Failure to secure 1 orkers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety i;
for a permit subject to the conditions and restrictions set forth on his':
application.
1. Each person upon whose behalf this application'is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify i
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representativese�f this City to enter upon. +
the above-mentioned property for' inspection rp'urf uses. ,� a
V ignature (Owner/Agent) r Date l " +
BUILDING PERMIT PERMIT#
!1!)410.-i4Z -
DATE VALUATION zLOT TRACT' #
,�13n .t� #2 i$
1- s .CI
JOB SITE
ADDRESS w5. Sl. -395 A FN10A �6: W'
APN 1
77;x443 -626
OWNER
CONTRACTOR / DESIGNER / ENGINEER •
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114.jAvtX1ll kA%.14 111'.
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PO IIO 134
4`3,"aAi��UASI�I.i> GrOi4 ST. ii'35S
LA f��lJf1Y�iA (11.`L 92255
DESERT" CA 92211,
.ALM'
'
USE OF PERMIT
POOL 11t DIOR �;PA �
POOL, SPA r12*IX7 GAJMPRN'WM1. (70 LF. ;q 0, dU Ldl., 51, 20
1_11*.: 41*), (.11.' V �'VANI)AXU
r
POOL A.i DIOs`,i, SPA: .LS
61"1'. "t+dtl IL 70.00 Lf
�
3.F1', WALL 40.00 LF
4 Fr. WAU 20.0o Lk
�, ' 1'."Ali T ;D COST OF M, N'S' RUCM N'
1"ii1)rM>Z"1'WE, SUMMARY
PLAN CROCK f'f E 101-0011-439-318 S76-05
(c>NtTRTjCT!0AiFR, 'i f) _M,041!84)(10 ?7i.Csf)
1bi13C4:A.141CAL.i"EV'•--POOL 101-000-421-000 $24.00
9d.'0'i'I2, CAL. VE- __ POOL 161-000-420-000 515.00
PLkT��1NQ 1' --POOL .101-000-419-000
CONFMCJC'DON ANIS 4`?.,A'hJ CHECK
$34105
r
a 9p� ,ESS 1'RU ID Z<'. ES
$01.00
PleR1ll;ff FEES DilCNOW
RECEIPT
DATE
BY/*I
DATE FINALED
INSPECTOR
.INSPECTION RECORD
OPERATION DATE INSPECTOR
u
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
0. K. to Wrap
Framing
Insulation
Fireplace P.L...
Fireplace T.O.
Party Wall Insulation
Partv Wall Firewall
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Drywall - Int. Lath
Final
Final.
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings, 5F
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
O.K for Finish Plaster
Sewer.Lateral .
Pool Cover
Gas Test
Appliances
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Main Service
Sub Panels
Exterior Receptacles
G.F.J. t
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)'
COMMENTS:
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