9904-168 (RPL)ai
Cl) IJ C
LICENSED CONTRACTOA*, DECLARATION
,-).here6y affirm Under pe ' nalty of perjury. that lam licensed under provisions of
Chapter 9,(6omm6n6ing With Section -7000) of Division 3 of the Business and
Proiessionals Code,a[nd my License.is in full forceandeffect.
License Lia Class Exp. Date
W3 M
Date I t t ',5ignature of Co�irkjioE�
;.'
r, OWNER -BUILDER
DECLARATION
I hereby affirm under, penalty of perjury that 1: am exempt. from the Contractor's
License: Law the following reason:
1, --as . owner of,the property, or my employees with wages. as th I eir sole
CoTpensatiori', will do the Work, and the structure is not intended or offered for
sale (S - ec.' '7044, Business..& Professionals Code)
as 'oWner7 of the property, am exclusively, contracting with licensed
contractors to construct the project (Sec. 7044, Business -& P.rofessiona.ls
Code),
I arTi exempt under Section .B&P.C. for this reason
DateSignature -of...Owne , r ,
' WORKER'S COMPENSATION` ' 'DECLARATION
7.'
l,.h6re1
by affirm. -under penalty of perjury one of the following declarations:
(have andwill maintain a Certificate of Consent to'se,lf-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.
have and will maintain -workers' compensation insurance, as required- by
Se9'tion 370Q of the Labor/, Code, -for the erform6ince of the work for which I t - his
.
ig _issued. Led. My workers' Compen . sation -insurance., cahr.i.er & policy no. are:
'
Carrier
''Policy No.
_r co 'WN V3034
(This' s-ecti-on need not be completed,,if the permit Valu'ation is for,$100 .00 or less),
certify that in the performance of thelwork for which ',this-perffiitjs issued:
T shAll,'not employ any person in any., manner so as to become subject to the
uv6rkirs"c6rnpensation 1Bws of California, and agree that if, I . should becoffie
S'ubject to the wor'kers',Compensaiion provisions" bf'Se6tion'3700.of the Labor
Coded sh 11 forthwith comply with th-oset'proVisions.
Warning:. Fpilore to secure Workerg'.&mp� sation coverage is unlawful and
shag subject an,employer to criminal oe'nalties'and cMlfines up.to'li,00,000J6
addifio'n to the cost, of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT.Apoiicati*on,is.h6reby'made to.the Director of Building and Safety
for'. a . permit , - subject
pct t - o the conditions I and.'restrictions, set forth ,on.his
application.
person upon ,whose behalf this app . lication is made & each pets I on at
whos . e request and for whose benefit w.ork.-is performed under or.pUrsu 6nt to,
�;'any permit issued as -a result
sult of this applicaton agrees to, & shall, indemnify
&holcl harmless the City. of La Quinta, its officers, agents and employees.
2. Any permit issued as" result of this application becomes null and void if
,a
work.,is not commenced within. 180 days from date of issuance of such
permit, or cessation.
n 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 lie'r6by authorize representatives of this.City to enter upon
the abbv6'mentionecl property,for inspection purposes.
Signature (OwnbOAgen L 6';l
PERMIT#
BUILDING PERMIT
9904-169
DATE VALUATION
si .1t)(1.00 LOT - TRACT
9,(
JOB SITE
ADDRESS 47�3*56 VIA CORDOiIA
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER'.
Mic"flAELBERZON CONSTRUMN
C.A.1-TUILLAP001, COIN-MIU=0N, INC.
7292,9 SKYWARD WAY
7
78-710 1A PALMA D k.-, LA QUINTA
PALM IMMEM' CA. _132260
PALMDESERT rCX�A220i
(760)MO.(Q2
I IRF nF PF:PRAIT
POOL ANDIOR SPA
POOL & SPA OMA r. ALARNI.Si%Nf)/CIP.BARR(LRRr�,Qtd-IRED AT
PR&PLAJSTf.;R (Jq8J�f'.CJ'J0JNL
DOL AMORSPik 19,000.00 I.S
ff.;STMIXTED MIR' or) C011111STRUC1101111
191000.00
PFRMIT FEE SUNIAMRV
_."PLAN CHECK FBI, 1,01-0001439-318 5128.70
Nf,804ANICAL 11"KIS -- POOL 101-000421-000
-BLEMSCAL Y1 X "POOL' 10 1700"20-000
PLUMOTNU FIM Pool. 101-000-411)..000 S27.0
81-113-TMAL. C(.kF1'RUC_!1QNAN!.') PLAIN Off -,CK
$422,70
LESS PR&P.,'UMFEE48
$0.00'
If MAL VERMOT FEM 013 E NOW
RECEIPT
DATE '1BY
DATE FINALED
INSPECTOR
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 8 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
Q
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
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
Cv
9--43-9 7 GAg-
Gas Test
Appliances
Final
(-
COMMENTS:
-
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)