0108-159 (RPL)LICENSED CONTRACTOR DECLARATION ,•
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commenc;iig with Section 7000) of Division 3 of the Business and
Professionals" -Code, and my License is in full force and effect.
License # Lic. Class i ^ ry a,M . Exp. Date
r X92,22:5
-..._....,.-
Date � t _ , i 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 sol i;
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-peejury 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.
ZYMPT
(This section need not be completed if the permit valuation is for $100.00 or less).
(.,e)r 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 provislons..of, Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: P Applicant -
Warning' Failure to secure Workers' Compensation:c6Verage 'unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
„ addition to the cost of compensat o,nydamages as provided for in Section 3706
of the Labor Code, interest and -attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. = k
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees..
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance cf such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with. all City, and State laws relating to the building
construction, and hereby authorize representatives rgf this City to enter upon
the above-mentioned property for i'nspectio`n purposes
Si r, nature•(Owner/A"ent)-.->-. �,-L x/7? f'--'`l:r'6 ��9 `:'Date AJ Ijg I
r }.
BUILDING PERMIT PERMIT#
,
DATE J / VALUATION LOT ��, j}j� TRACT
'f a li +f +�./T Y aC,y,TLDEJY,9.�iJi7
JOB SITE c.--
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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I I F ca'I'I.�at�i�iDd+A'.Y 4� r u • S,
PAi:IMM1;8M CA 92260
;VALVA D* S`,'Wr CA S72260
Cr nU) 340-9882 GSL# # tA2E
USE PERMIT
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.i' 9.iM d"t8.9.1.�:IOR SPA
POC,x RA.. ALARIVISMARPURS SHALL BY, IN 'PLW? AT PRF PK AISITFR
II.48PkefflOtl, POOL EQUIP%T3 OT ENCIA)B7. RE NOT INCLUDED.
POOL , NDIOR,SPA LS
E91INKMD CM N- ' d^i'3 i'��$ "' O► $
fir, i94D.E
PIM CHECK FES+. 1,01-000-439-310 $52.61
WAlaT?•<:UC T 1rJY+7 RE b b l-00f14I R-000 "1.00
WCHMICAL OBE, -- POOL IM -000421-000 $2.1.0
E -L- ;'PI 7.44.L FM -- POOL 101.00..0-42.0-000 $45.0
PLU MPTHO M --. K*L
t,
: 4"
ORMPRU TNOati AND PI" c;���
$229.6s
I MiS 1''a` Tt 4"PAED FTM 3
$0.00
3'EMM.TYU, 9 DI,O; NOWI
A11 16 2041 °
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RECEIPT
DATE° / ='
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Farms & Footings
Ducts
Slab Grade
Return Air
•G.teel
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
POOLS -SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Steel
Electric Bond
Main Drain
®.. Q, v i
"1
S�
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
5.7
Underground Plbg. Test
1000,Q'-(
Final
PLUMBING APPROVALS
Gas Piping
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
Gas Piping
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
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)