0006-374 (RPL)LICEN TRACTOR DECLARATION T
I hereby affirm under p erjury 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
238947 G� + /� 03S31f2f
Date %" Signature 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 GOLDEN KAGLE Policy No. NWC381861-00
(This section need riot 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 athat if I should become
subject to the workers' compensation provisions Srof Section 3700 of the Labor
Code, I spall fo hwith comply with�th se rovisions.
Date: 4�,J'�»�" � Applicant W
t'
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 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspe ion purposes.
Signature (Owner/Agent) - Date ✓� a4 B ;
4"56 -C") BUILDING PERMIT PERMIT#
DATE VALUATION s2 m0`i.00 LOT TRACT
JOB SITE ADDRESS OD -4,20-P
APN y -
OWNER
CONTRACTOR / DESIGNER / EN &NEER
I1ti NOVA X'1Vlr,M0RT CONMW1S9, RC.
MASTLIR POOLS
200 , WAd%- MSOTON AVF_ 0100
73-555 M(iHWAY 111
FSC0N7'1D0 CA 92025
PALMDESM CA 92260
(760N,346-6115 CEEB. 0016
USE OF PERMIT
POOL AND1013 VA.
POCIL & SPA ONLY- AJ.ARM.%MARRiFRS SHALL BE :1N PLACE AT
PRE-PLASTUR DOPECTION, THIS P&ItMIT DOES NOT a4CLUDE Et1.00K
WALL FOR EQUIPMZNT MCLOSURF
VALUATIO14 A0001 LS
I:I 'MIX .'Fi) COST OF C0XS'fRUC`_`10XY
a1�,i30D.0U
1: RMT FT& Si7 4>RY
PLAN CNEV-9 IEEE 101.000.439.319 $146.25
CONSTRUCTION PEE 101-000-418-010 $225.00
MWHANICAL FEE -- POOL 101.000.421-;100 $24.00
ELECTRICAL, b!C -- POOL 101-000-420-000 $45.00
PLUMBING FEE -POOL 101.000,419.000 52°1,00
8"UB-7.OTAL CON Sni UC TION AWdI) PLAW (25,CK:
$467.74
IMS PRF-PAff FEE;
$0,00
,yrs TOx'AL 17'>J1a' 1VC)W
W7,25
j, n
— , � � I%'
wf�
RECEIPT
DATE
BY
l
DATE FINALED
INSPECTOR .
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
a.. 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
=� s
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: