0012-198 (RPL)LICENSED CONTRACTOR DECLARATION
I Vhaff icr m u n d e enalty of perjury that I am licensed under provisions of
r p
C h mmencing with Section 7000) of Division 3 of the Business and
Pr Code , and my License is in full force and effect.
License # Lic. Class - Exp. Date
. 68689.5 C-53 W4012(
Date
Signature of Contractor—
OWNER-BUILDER DECLARATION
I he�eby affirm under penalty*of perjury that I am exempt from the Contractor's
License Law for the f6ll6wing reason:
( ) 1, 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).
1, 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-insur6 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 andwill maintain workers' compensation insurance, as required by
Section 3760 of the Labor Code, for -the performance of the work for which this
permit is issued. My workers' compensation insurance barrier & policy no. are:
Carrier VrATE FUND, , .. Policy No. W082-01) I .
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I cehify 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 37bo of the Labor,
Code, I shall forthwith comply with those provisions.
Date: 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
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 a
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 inspection purposes.
Signature (Owner/Ageht) Date
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
80-4:&S WKISKOPF
OWNER
CONTRACTOR DESIGNER ENGINEER
14gm nvzwwx
CALMORMAPOMS, &SPA4
$0,455. WEIRKM
74-725 JOR1.1)KNE, 01�
LAQUMA CA 922S3
PA.LM MEMO* CA, PZ260
Ci6Q)340-9(= MIX 5386
USE OF PERMIT
POOL AWYOR VA
SOOL & SPA'ONLY-AIAMNISIBARRIFOS SHAU, BE, IN PLACE NT 'Okly,
MAMA, IH.8PFX�'ffT0N,PO0T_ FQUfPMF',NT Y,?T4C1X)SURF, is N01, amwmo
fN THIS PRRMIT
P0014,ANDIOR VA BIB". 00 US
ZIMTOWZ0 COV W1 CONFIRUC710M
PERAR,r FET 9UMMANY
PIAN CNECK FEE 103 -0M439-3 18 $11
CONSTRUCTION FEE iol-00"18-000 $171.00
MECHANICAL ME — POOL 101-000,421-000 $11,60
Z1,EC'1`RJCA.t, "W .. K)OL 10 1 -00"20-000
PLUMMO FU POOL 10) -000-4-194910 127.01)
SUB-TaM, 0�34 &RUM100 A14D PUNWMECK
$378. 15
LEXIS 11RE-PA-M Wes
$0.00
r3 J%
IYMAIL, ITSWKYWE 9VUSHOW
DEC 2.6 2063
9178115
U LA
Q-UjN1
RECEIPT
DATE
DATE FINALED
INSPECTOR
IBY-3x�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Backs
Underground Ducts
Forms 8 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 8 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
y
Final
Gas Piping
Af
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.1,
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: