0401-269 (RPL)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
C -84
I oil f
Date 1•-+t Signature of Contractor r, •i`K�.--"
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�'Tr.,f TF, �"i;3?�.�'EN S.E� T,B Policy.No. (�6 .i C$ L► �i
.(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,1 shall forthwith comply with those visions. ,
Date: /: t " ,' Applicant % ac;.. J "d,
w. fiv
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 Sectiow3706.
of the Labor Code, interest and attorney's fees.
i.
IMPORTANT Application is here6y.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 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
yffo inspection%purposes.
Signature (Owner %` Date'1`-f r��_:•
8. Y
PERMITN
B��I•LUN_G PERMIT:
DATE � VALUATION ' LOT "' TRACT
j�
JOB SITE
ADDRESS df9-439 V.iA CiC. NQUI VADOR
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
111) MeS f T 17LIVIa.G1'.14-fiNi
✓ ALTFOMIA 170oLS & .4s crop kAAX M°0
200nX 1,716
$6- 1.o0AGEiur_? 54
5ppquVAA. CA91253
COACIMA 4A 92236 6
60)398.9222 CnB 4 00355
USE OF PERMIT
P00 ,Ml:'t UR. VA
P003./JRA. 400 (.P IISI 71.58.39951 yt'IttkNT ($96ii::,t L)
WAT.MFU l %iJ"h ='aC,ARDAWBAft'kli , AD SH., LL BE IN PI At EAT
PRIE-V1;AS'P)»R INSPECTION, -EQUIPXIENT E14CLOSi!RE\NOT 134CLi33:9 D
P00L ANYWO 0PA " AMA LD
COST L%+C' is4 N.17.t.T.6+cJau1111&orf
; jjy�p+�tPp
. . �C�a'1N•+WrVfA
wu��r��1cyF.idJ7ALSAY^.M
d�g,e �y wig �g;� `4 MGM,
.tr AyYi M:�7,T A1.A'�-49�MJ.lYG/.VSis•._a. - -
PLAN G9-5►K.M F & 403.000-439.3),8 $134.35
COU'3.I.32U ,"IO ELP 101-000-118_00
MECXIAMCfi., , FRE - POOL 101-000-421-000 $24.00
LK,T,RtiGAi.'f�f� :w.POOL 101-000-420-000 �s.Afl
PLAININHO FEE POOL 161-OVU-419-000
9Tt#li-'1'�"i:xAXI C0Nhn_`k1 C110W AIM PLAN f. '.�l:�:CrK
$13:!.55
LFU53 PRM -71?AM MIS
$0100D
JAN 2 0 2gg
CITY OF LA QUINTA r
FINAi4Csv DEPT:
RECEIPT
�� -
DATE IBY
-.
ti t __1:,41 -
DATE FINALED
L
3- - /
INSPECT
U;
"µay
;f
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 peck
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
111Y
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
2
Electric Final
--
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
..l ewer 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)
4--