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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
�661�4611 C53 M13112(
Date aaSignature of Coq tontract
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).
( ) 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 -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:
Cartier €3 ME''QUND Policy No. 045.1CAM
(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�ection 3700 of the Labor
Code, I�sh II ort with comply w'tbi t os' proviii loris'.
Dater Applicant --^- -^----—"'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, In
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, Interest and attorney's fees,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
11 Each'person upon whose behalf this application is made & each person at
whose'request and for whose benefit work Is performed under -or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, Indemnify
& hold harmless the City of La Quinta, Its officers, agents and employees.
2. Any permit Issued as a result of this application becomes null and void If
work is not commenced within 180 days from date of Issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above Information Is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for Inspection, purposes.
Signature (Owner/Agent) „%�����-�"�- t--•,"�—=Date -% � 4
BUILDING PERMIT PERMITT##�
DATE { � VALUATION s1 �y� LOT 24 TRACT
. kl�. �JOB SITE awti
ADDRESS s0} MIS C_*'.��l�i,?ADA '.,OSI ° APN
OWNER ICONTRACTOR / DESIGNER /ENGINEER
a�'D:N.Et4.HOMPS, INC '„4i�i,11Wf YRIJt()ciLS1 LQSr,.4413
7-7 -564 CU'CEN'.I'RY CIL DRIVE. U'U'J 1S 1,.;7 1a.O.:BUX 1791
PAUKDRS-M CA 92211 1A QUINTA CA 92253
176.036093585 CSU1915
USE OF PERMIT
PO OL AWYOR SPA
POOL ANO SPA ONLY 1t 40. dtNM4P,,A1 RJ?,RX ShAl L BE INN PL/1 C8 PRJOI2
TO PRAPIASTX11MES'PEf;`i°;c�i'a.POOL EQUIPMe'NT 9ftyi..t38+,QU:,, NOT
INC1LULJF,'t0 TAT PVRM i.
FOOD, ANDAM, SPA
1$,w. (lo LS
17.117M'.1la.'1C D COST OF CO NIS"YRyl3CT10H
RAM CHTECK YZE 101-000.4359-2-11)
CONSTRUCTION Z 101-WAO-418-000
MECHANICAL TSE POOL 101-000-421-000 124AID
ItTLECTRfCAL FEE .- POUL 101-00.420-000 $45.00
tPLili1►lSi:411~l'0 F'rE - POOL 1£11.000.419.1000 W.00
RECEIPT
.D e
0 21001
CRy0FIA0UI1RA
JX3 i PRE -PAID khM-
BY
FINALED
r-- JT ---5
,c51VW100
$1.63.'30
MOD
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 y= 7- L
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Fina
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
(/
Gas Test
Electric Final. _
Waste Lines
Heater Final _
Plumbing Final
Water Piping
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
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)
.
I
RE -INSPECTION FEE OF M
THE;x..
WILL BE CHARGED ARD ARE NOTI
ED ON
PLANS: AND JOB
THE SITE FOR A SCHEDULED
G
F t. ', IiVSPECiION. .
M .NO EXCEPTIONS!
Ili
PEBBLE
BOLDERS,
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6'x7' -6'R
CONCRETE
STONE SPIV
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BOLDERS,
RAISED BO
9• WITH CON
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BOLDER,
I
I BOLDER, 1