0207-180 (RPL)U)
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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 `
oo 614611 C53 3131f03
Datef Ir�''- Signature of Contractor�+� �V5'" C
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. 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 7TATE:PUND Policy No. 0610416.02
(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
Code, I shall fo hwith comply with those provisions.
bate: `17hrn - 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 Quints, 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 suc
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information s
correct. I agree to comply with all City, and State laws relating to the buildi
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes. t
Signature (Owner/Agent)_w” Date
"BUILDING PERMIT PERMIT#
02(17-180,VALUATfON
DATE 4t...».-',;,,�ti
����•� - LOT TRACT
JOB SITE
ADDRESS 50-] 15 C-�ADA COV
APN
-
OWNER i
CONTRACTOR/DESIGNER/EN (NEER
0k>'. 034A iiUMlw'.% INC
MC'IL�ME.T 001.81 &',W AS
17 -6 C4 C'c9tMTRY C!',UBINUVE'S"MM 137
P.0, BOX 1751
,r�..;Rd1 DRM l Ji 9y'tl l
7 fii�ds"�F�i CA. 9225:3
('7,6q)360 -x585 (TUA 1:45
USE OF PERMIT
J)t3(DLA�lt OR SPA
INSPECTION. EQUIPMEWTENCIJIM, URE NOT MCl:UDED
POOL AV DIOR SPA IAi,UA N! IX
UUMNIMD 1%'OSIr OF COINS111UMON
PLAN CHECK ME 101.00M.3.9-318
CONSTRUCTION FL,1? 101-000-418-000 $162.00
I't€FKWANlCs, 1172 -- POOL 101-000-421-000 $24. 1
MECTC3iM ME- POOL, 101-000-420-000 $45.00
PLUMDA-440 FZE » POOL 101-000-419-000 s2UO
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CITY OF LAQUINTA
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
INSPECT R
�00
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
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS
72Co2�
C
Footings
Main Drain
Bond'Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
V%&ste Lines
Heater Final
Miter Piping
Plumbing Final
_
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
p • a ?/
Gas Piping
_
Gas Test
Appliances
Final
�
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)
COMMENTS:
PEBBLE FINISH
�IaCi Wq5 ,DI
ISED SPCA AT +18" WITH
GAP AND �STAGKED STONED /
AND PEBBLE FINISH. POOL
POOL EQUIPMEt
RAISED BOND BG
WITH CONCRETE c
7-7
ENWOM ... .:.:.:... .. • •: .: • .. . • •..• •• •• FI NISH GC
DEGKI
• � ' .• • � .... `• ' • � N6, COLOR
Awl
. •• -PDr PDQ •
mr "ODIC
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7,Mow
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I PLAN 2R
A RE -INSPECTION FEE OF $30
y WILL BE CHARGED IF THE APPROVED
RN6.-4O6%CA_ RQ.ARE NOT4N
=,f THE S`jTE FOR A` :SCHEDULED
"`'��t " �'�'�t ��• �"�` ,� ' 4y,''� ` INSPECTION .. ,...
:NO EXCEPTIQNS�
�f1t ����:{�`. .�„ i:i}���iRf, �. hr ��'i �� •i,F��Y," „ .. •1. s, .r. a '�'
Fr
I CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE - .. 30 -OZ BY.. .