0004-205 (RPL)LICENSED CONTRACTOR DECLARATION
U) ..I hereby affirm under penalty of perjury that I am licensed under provisions of
H r Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
0. Professionals Code, and my License is in full force and effect.
O :D c.,) License # /` Lic. Class Exp. Date
CY
� W 0w1/2L
6Z10aate ` ` % Signature of Contractor
CDO�
J U � OWNER -BUILDER DECLARATION
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) I am exempt under Section , B&P.C. for this reason
Ln
N Date Signature of Owner
O N
0)
FL Q WORKER'S COMPENSATION DECLARATION
> fr I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD Q CJ ( ) I have and will maintain workers' compensation insurance, as required by
OLO Q Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE Ir ND Policy No.
co 5 229.99 UNIT 06{14403
�a
J
(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
`> worl ers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I s all fo . hwith comply with those provisions.
pate: % Applicant
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
11110 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
4 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 t
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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection,purposes.
Signature (Owner/Age6t) 1 Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT` TRACT
04/19/= d t i9.d9G 1 N BLX183 Ul8
JOB SITE
APN
ADDRESS ii,amAsalt
774-071-1923
OWNER
CONTRACTOR / DESIGNER / EN (NEER
STARLZtIHT MANCr>+ lvl . r IANC
W LLUM RUSSEt.L RC*ff<JS
PO BOAC 3578
56900 Mr -143014
PALM D EWf CA 92261
71 ER AL CA 922.74
(760)399.1200 CU1:.4'# 1954
USE OF PERMIT
-I',,
POO PA -MIO& IPA
P00i: Cjwx. I.LARMMA I'.i' ERS SHALL BE' M PLACE Xf I?1;Ir MASTER
114'SPEPCTlON
v
VAWATION 0,000,00 LS
v
ESTMA17 111 COST OF CONSTiki71;'IMN
8,000.00
VEFtWf r, RE GARY
PLAN &HECK FSE 101.000.439-318 $64,35
CONSTRUCTION FE? 101.000 -*118-000 $99.00
MECI1MICAL FRF. -- POOL 101-000-421.000 $24,00
F'LP.CTitli::.l L i+'E •• FOOL 1011-000-4213-000 $45.00
'
PLUMBING IEEE •- POOl, 101.000-419.000 127,00 "
«
�t
l� y�
,T «
;. SUB -TOTAL COM UMON AND PLAN C'IMCM
$259:35
` LESS PRE-PAIDMS
$0.00
• TOz'tlL FIEF" n_IIEN DUY, 1�30yV
9�
4
RECEIPT
DATE /
i
/BY /
f/ ZLi
DATE FINALED
INSPECTOR
INSPECTION RECORD
4.
4
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
Set Backs
steel
Electric Bond
POOLS - SPAS
_
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
S _
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
f
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVAL'S
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:
cli 50'
Ca
40.
5' BLOCK WALL
Lu
RAISED WALL t
3-
3'.j 5'B"17.P. 4'D. P_
LA
-v POOL EOUfP _ E
3'D. P. IF -,S --
QO S. GATE;
j ENC" SEAT M E
1 R ET.
Q 8 A RE -INSPECTION FEE OF $30 '
WILL BE CHARGED IF THE APPROVED '
PLANS AND JOB. CARD ARE NOT ON
tU THE SITE FOR A SCHEDULED
INSPECTION.'
.NO EXCEPTIONSI CITY OF LA Q UJ NTA
BUILDING & SAFETY DEPTi
APPROVED
--� i .6" S. C_ GAT FOR CONSTRUCTION
G
----- DATE 4Y '
r
HOUSE
-gas �-,A�. r
t