9905-187 (RPL)LICENSED CONTRACTOR DECLARATION
,'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
�i90645 8
_4p
Date Signature of C6ntrac r --------
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
Codej.
).'I am'exempt unde r 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:
( .) 11hive and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section �700 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 3100 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.
',LND
SM E _11,12Y.
(This settion need. not be completed if the permit valuation is for $100.00 or less).
,P(�) I certify that in the performance of the work for which this permit is issued,
/61,sk'all 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' compens�tion pro I vision . S`of Section 3700 of the Labor
Code, 1�ha,1,1,f. rthwith compliwith tho-s'e' s.
provisip
L
bate':*-, Apol'icant-5" 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 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 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 th at 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.,authcirize representatives of this City to enter upon
the above-mentionecl-p�6perty forih's�ectip6 purposes.
Signature (OW9er/Agent)-,K Date<
PERMIT#
BUILDING PERMIT
9905-187
LOT TRACT
DATE VALUATION %,
JOB SITE
ADDRESS 54-595 G"ND MAWERNE AVE
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
PUT 1-110NIT. S, 11 41,C
r TINT V F 5111 F NNTS, IINCAUT
POSOX810
1425 E. UNIVERSITY DRJVF
LA QUINTA, C.A 922-53
PHOENIX AZ 8X)34
(&)2)2 57- 16.56) C'BLY 4990
USE OF PERMIT
POOL AND/Ok SPA
T,00USPA, iV1,ARA14i6AR:R.Y6RS STfj�LL fiE JN A37
POOL Al 4WOR SPA 11,000,00 LIS
E31,1111A 1, ED CON r OF
11 '0140.0 11. 00
PLAN 00ECK, FHE 101-000-439-318 118 1.90
CONNIMLIICTION ME 10 1 -00( 11-41 ��-W) 1111 216. 06
.10 1 _W(�, A� 1..()00
N01111AV'ICA.L M- -- POOL A . It4 S24M
L, uecqlocf�,L ru � POOL 101 _000-420-000 S45.W
PLUM9.11400A., POOL J,01(PJ0-4JM00 $27M)
S111.3,I'MAL C'ONVI RUCTI.ON AIND P!,AN CH11',CK
$3103!)()
LESS PRE-Pl�UDITES
X00
TOTAL PER M YC Vle," 01) U N CM
RECEIPT
BY
E FINALED _T�`PECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
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
CO -/A- - C?
Underground Plbg. Test
Ic
Final
Gas Piping
f
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
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)