0111-160 (RPL)C/)
C/)
N_ LU
O :)M
d
oZr`
O O
H
LU a r•
N
Z
M
IO
O�
�a
Z
Lo
Q O
0 Lu
J J
m<
O
MH
v Z_
of 5
r� C)
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of 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
614611.
Datga,11" Signature of Contractor 1r __,,=3
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. 7b44, Business & Professionals
Code).
() I am exempt under Section , B&RC. 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:
Carver STAff, FUND. Policy No. 046.01 G0ltM
BUILDING PERMIT PERMIT#
Q ii E �e VALUATION LOT 0IU- 60 TRACT
3
17 1 /1 t S,tid3£� 4 3 2�s2i� �2
JOB SITE APN
ADDRESS �R- fg) 00103 =WDR'ITVrTS' -
:AWNER CONTRACTOR/DESIGNER/ENGINEER
W1r' 'l.+ RN Y?OV-40C lutCM" AR P001-47 & SPAS
8 1 -220 UE GENDS WAY P.01 Box 1791
1AQIJt1RMA CA. 92253 LA,QI TA :CA 92.233
C/60).; 60--058.5 CBVf 194. .
(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' com6erisattiion provisions of Section 3700 of the Labor
Code, I shall forthwith comply Ith those provisio S.
Date Applicant i'%,
a.
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 17ti
tY
,of the Labor Code, interest and attorney's fees. i
USE OF PERMIT
P00'L MINOR ,SPA
P001APA..ki.; AR-AMAU-i21;1fZ.1MS 3Hfs.W., tfLE IN P'IACN ATP iIM,A.STY1.K
INSM17:MON. !POOL VQUl!;Ii+ ENT 13-14CLOSURE. NOT Mr."LUDED
POOL � NEVOR SPA
1.000.00 1A
f:�.,e7R:kiY.dRsd.13Y.D 6sOFr ANSI CO.I.VV 1W.-4 dt.E014
ALM CHECK FER IM -000-439-318 MIA
C;1NS'd'C3, 0'1301+! PXV, 101_000418-0100 X562100
MWIWACAL RE -- POOL 101-000421-000
R'LTMTV1CAL I'VE <-iV40 }L• 101-000420-OEDfd S.fitl
PL11.iktirl, O FFY, -- w0 t .,4 101.000.419.000 MAO
IMPORTANT Application is hereby made to the Director of Building and S'f
-f
NOV
for a permit subject to the conditions and restrictions set forth o
ii
application.
1. Each person upon whose behalf this application is made & each pers
to a '
GY®I,
whose request and for whose benefit work is performed under or pursuaint
to
FINAL
any permit issued as a result of this applicaton agrees to, & shall, indemnify'
—
& hold harmless the City of La Quinta, its officers, agents andemploybes.
2. Any permit issued as a result of this application becomes nulr 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 of this City to enter upon
the above-mentioned inspection es.
prQ�perty,for purpo
� ^".�+�✓ - 4/
Signature 4"L-�A.`�/`-.�^� �6at
RECEIPT
(Owner/Agent)
21 NMh
DATE
I I
1XM MOB -PAW 1:' , ,,�
BY I DATE FINALED
INSPECTOR
$363.30
WAY)
0W
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
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
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
/
6 10
/_C
✓
Final
Gas Piping
�fjl _
PLUMBING APPROVALS
Gas Test
r_
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
/2
Gas Piping
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)