0004-051 (RPL)LICENSED CONTRACTOR DECLARATION
'I here b\ffirm, under penalty of perjury that I am licensed under provisions of
„,Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
F;Z: fessionals Code, and my License is in full fore and effect.
License # Lic. Class j; ?c Exp. Date
'/te
5715$'P.. 1�A ,(�'�09/.30/2(D Signature of Contractor 3
.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. Businass R Prnfescinnalc Code).
( ) I, as owner,of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). • '
O 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 selkRsi-'re for workers'
compensation, as provided for by Section 3700 of the --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 EXEMPTPolicy No. .
(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 Californi -and agree tha if, I should become
sybject to the workers' compensation provisions of Se tion 700 of the Labor
Code, I shall 6 t With comply with those provisions.
Date: r� Applicant t
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and Jil 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 ser 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 withpll-Cityyand State laws relating to the building
construction, and hereby authdrize •repro entatives of this City to enter upon,
thWabove-mentioned propertyfo)anspectlo' purposes.'
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE�GVALUATION _ LOT tfAd 111 TRACT
aa qq gg //y9i�pp QQp�m�
$SJ,VIR7�\7il
JOB SITE
APN
ADDRESS 78-715 VIA CORR =
r
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ROIMA h HILL
VKAW WCIWL DUFF Y
7U-715 VITA COPRYMO
12930 ELM Rata COTJRT
LA QIM TA. CA 9225-1
YC.►CAIPA CA
92399J
�T;#
(760)341-011? MIR 16211
(
i
U3E OF Ythmi I
POOLSOP.. SPA
POOL & Si A ONLY-AL.h RM=At`'+,R M SAALL BE IN PLACE AT
PRE"` -PLASTER INSPEG f1014
VALUATION 15,000:00 1,,9
ESMMT= COST 0:0' CONS1RUC ION
3.5,000.00
PERMIT YEE S UbDAARY
PLAN CHFXK FEE 1.01.000-439.318 $105.30
C014STRUCTION FEE 101-000415-000 $162.00
MECHANICAL FEE •• POOL 101.000-421-000 $24,00
ELECTRICAL FEE •- POOL 101-000-420.000 $45.00
PLUMBING IEE •- POOL 101.000-419.000 537.00
St3B-TOTAL COhT875<UC'I109 JWD PIAN Ck ECK
$363.30
IMSS PfiE-PATD PUS
-; $0.00
TO'T'AL PKI?W'T' IMES DUE NOW
RECEIPT
DATE
Bf^j 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
CK to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond..
POOLS -SPAS
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test��
Final
Gas Piping t
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
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: