0005-240 (RPL)LICENSED CONTRACTOR DECLARATION
!<reby affirm under penalty of perjury that I am licensed under provisions of
iter 9 (commencing with Section 7000) of Division 3 of the Business and
Nssionals Code, and my License is in full force and effect.
LU �. ense #
Lic. Class Exp. Date
gyp. � M. i
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,'- w = 61481 ] C53 + 1
oZ r- Date �•� �� ® Signature of ContractoQ__1.,--_4-___
to 0
J U C:) OWNER -BUILDER DECLARATION
HUJ r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O�
d Q WORKER'S COMPENSATION DECLARATION
o cc 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 Y: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
CD Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
CarrierSTA 1NSURANCB Cf Policy No. 1114'11 i�34.0Q
ob
0
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
workers' compensation laws ofCalifornia, alifornia, and agree that if I should become
subject to the workers' compe lsatlop provisions of Section 700 of the Labor
Code, s a#� mtF comply wTtthose� provivisio s.
Date: Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
14
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
�\ any permit issued as a result of this applicaton agrees to, & shall, indemnify
dao & hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby 4uthorize representatives of this City to enter upon
the above-mentioned props for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
.
DATE /';VALUATION ZOT2� TRACT
�%.V
SISM0.0o
JOB SITE
ADDRESS GOTIF
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
R=LY HOMES, INC.
MCgM `n. E POOL.3 & SPAS
23 COIRPORAM PLAZA, #245
P.O. BOX 1791
.IaWPOW BEA.C'I--1 CA 92660
U" QUI T Ik CA 12.253
(760)360-3585 CH14f 1945
USE OF PERMIT
POOL MWOR SPA
POOL. & SPA ONLY-AL.rrgti2M3/8AR.RIER3 SHALL BE IN PLACE A; PRE
PIASTER, INSPECTION. POOL EQ.UiPM1ft. NT kHCF43URE IS NOT INCLUDED
rN THIS PERMIT(I) �
POOL ANDIOR,OPA I$Xtll.00 L3
ESIUM < D COST OF CONSWUC; LION
15X0.00
PERMIT FEW SU39i1il3ARY
PLAN C1 EW9 FEE 103.000.439-318 $IM30
CON"STAUCTION ..M9 101.000-418-000 ` $162.00
MAECHA141C.AL FEE -- POOL 101-000.421.000 $24,00
91.2,CTfUCA FEE .4 POOL 101-000-420-000 $45.00
PLUMBING -POOL 101-000.419.000 $27,00
SUB -TOTAL CON$TRUC`CIO.9 AND PLAN 0131.�.CK
$363.10
I:.EM PRE -PAID
$0.00
'3°C) rAL P`F_R r .VM DTTE .I`YOW
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR Y
y
,INSPECTION RECORD
QPERATION 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.KAo Wrap F.A.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wali Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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 / /I
Final
Final
COMMENTS:
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
Notice