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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: Claes i, Exp"Date
�►5�7 �� '<;33 iT(C C%�S � lt7l'3iY#iii
Date /o iO f Signature of Contractor
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 oroffered 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.
(f`), 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 STATIC i;:Ol. PENSAM Policy No. 046MO6163
(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 pe'rmit'is issued,
I shalt 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 becor�T�
subject to the workers' compensation provisions of Section 3700 of the Labbe,.
Code„ I shall forthwith comply with th 1) provisions 11
Date: mi�°;.: r Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful aird
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 37 E>;
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on t s
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 ofsuch
permit, or cessation of work fol 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 purpose .
Signature (Owner/Agent) �� t �J Date
PERMIT #
,BUILDING PERMIT2���
DATE 1 VALUATION ds'i4iQ.�� LOT TRACT
JOB SITE
ADDRESS 5D-495 IIUM, GLFU' APN
'J�.�
OWNER
11) TJF:Tcf [lVr-R 01':4vW..NT
1^0 171.6
T -A o,,111NTA
USE OF,PERMIT
Y'00 ANVOR ;"IBJ+,
CONTRACTOR/DESIGNER/ENGINEER':
CA LTi?'ORNM.FOO. 13 cr!`i:,# 1A (10P IV!'M
f4 25 JON1 1D EVE, iUMOAt,
Cfi. 92213 'ALM T. ESPO:T 'CA, 92260
(7 60)340�9000 MIX 00355
;r&A'40; 17'!Jr a& A[M1.r
1K PIACE.AT f RE. PIA.01TER 1HOPF,CTIONr POOL TZOfJlPMIDIT
ZNCi SJSURE NOT 1Nt:'1111iDFID.
P001, AND/OR SPAS
25,040m) LS
CBCT P � M,
C r,. V OF ! A ilUI TA
FtNA_mc 5� C) -'-?T
RECEIPT
MB-1)(NAL ('0N8TKTC :r 10)4 AND Z)LAN Cr'TE:0C
IMP PRYI-PAM 1,173
': /
BY
INSPECTOR
$511.80
50.00
ZSI]:8d)
P ERli'TU M 91MM RY
PLAN Cj•1r'. X FEE
101-0001439-318
S161180
CONSTRUCTION FEE
101-000..,415-000
0232.00
MEChiAMCAaIL FEE -- :.P(*L
101.000-X121-. D
$24,00
ffI.i.:::7 RIC,Al. VEX - POOL
101-O i-,42•t'34lflt!
545:00
i'Ltiii PID10 FOTO -- P001b
.. 101.0001.41 -Mo
OO
MOO
CBCT P � M,
C r,. V OF ! A ilUI TA
FtNA_mc 5� C) -'-?T
RECEIPT
MB-1)(NAL ('0N8TKTC :r 10)4 AND Z)LAN Cr'TE:0C
IMP PRYI-PAM 1,173
': /
BY
INSPECTOR
$511.80
50.00
ZSI]:8d)
INSPECTION RECORD
OPERATION DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
I
I
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
j
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
I
I
Grills
Fireplace T.O.
Fans & Controls
Condensate Lines
I
l
Party Wall Insulation
Party Wall Firewali
Exterior Lath
_Drywall - Int. Lath �f
^II
_ 1
Final
— —
BL0C1':,,'-JALL APPROVALS
Set Backs 1 I
Final
POOLS -SPAS
Steel
Electric Bond f
Main Drain
{ Approval to Cover
Equipment Location
Underground Electric
Underground Pibq. Test
i Gas Piping 09
Gas Test
Electric Final
Heater Final
Plumbing Final z
Equipment Enclosure p�Ca
O K. for Finish Plaster v '�
I Pool Cover _
Encapsulation
fcotirga j
Bond Beam _ _
_
^�
Final I —
o f r. E I r; G
�` e�ae as�c�ROVALS
Waste Lines _ � � �
Water Piping i _
Plumbing Top Out
Shower Pans ~l
Sewer Lateral
Sewer Connection
_�
Gas Piping
Gas Test
Appliances
IE
I Final
_
J
COMMENTS;
Final
Utillty 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)