0011-103 (RPL)LICENSED CONTRACTOR DECLARATION
t hereby affirm under 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
Y 28, f 9f C-1;3
pate Signature of Contractor
OWNER -BUILDER DECLARATION
10/3112(
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 toyconstruct 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 Policy No.
1UDLAWD BNI4URAN, M0991938
(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
Cyde, I shall forthwith 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 $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify '
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all •C-,fty, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date 1
BUILDING PERMIT PERMIT#
DATE , VALUATION LOT, TRACT
JOB SITE
APN
ADDRESS
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OWNER
CONN)RtAYCTO[RT/DEfS�IIGNe2E7R./�EiNt�INEER
r S/ �yL L� 7� /yA tt l�Tyt7 Tt •y p�+p
WI ZV . V A •6 .3 RY'Hc." OR- �:V.iviCaiVF'61xiX' 1, WC,
.L7tJS.fgJ.Z SlklL.i:610S
200 K WA INCrMN AM #100
71509 SAO CTC=0011,410
ESCOMMO CA 92123
ECHO MEM SE CA 92270
(-160)341.2336 C V) 5486
USE OF PERMIT
1TC1f 1, fiNIXOR SPA
PCYDL) &SPA ONILY-AL„klt,W/DAMES:.; SHALL BE IN PLACE A'I°PRE
PLASTER 1148PF.t",TION. POOL, EQUIPMENT MHCYt OSURK tS NOT MCi,UDED
IN THIS KId,LIQ T
POOi.ANU,`OR IPA 00 I.$
PIAN C1 ing RX, 101.000.4319- x i F, $222.03
COINSI'I UCT3f N FEE 101-000.418-000 5.103.00
MES:"14AHICA•L FFF -- POOL 1014=421-M $7.4,00
ELECTRIC -ft. i USS: - POOL. 101-000-420-000 $45.00
P1.4316.10ING nE -- POOL, 101-000-419-000 !S2"i:00
r
+ry']`�; pip'
y��+� �^t �,yM�j;, �a'�`{/'gyp{.g p'j q`� PLM
1SlA,f.YD.•\ aA l ,I CI�")NE .R.,C> 6,Ai4J � k1l) Jai .J.'iC'd ��i::il.t K
a7 1 .95
IMS FRE-FA,ID 1?13-W
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$0.00
by FFAMT F.I~.'ES 111•CIE 14 -ow
RECEIPT
DATE
BY /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
0.K to Wrap F.A.U.
t Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Walt Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS Steel / �A
Set Backs Electric Bond / v/_X .(�
Footings Main Drain /
Bond Beam Approval to Cover
Equipmen_ F,n _
I erground Electric _
Underground Plbg. Test 8l:30ln
Final Gas
PLUMBING APPROVALS Gas TestElectric Final
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 _ /J
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)