0210-213 (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. Clas' '` Exp. Date
Date Signature of Contractor s*.
1� 4 .
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
''Rpermit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier )qjj) Policy No. 229-P240193U
(This section need not be completed if the permit valuation is for $100.00.6r 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 Californtia'',tand `agree that if I should become
subject to the, workers' compensation pr'ovisiow6i Section 3700 of the Labor
Code, I shall forthwith comply witht6i_ provisions\
Date: Applicant—
Warning:
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 Saf9ty
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 1;v
& 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 "i s
Correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize'representa4ives of this City to enter upon'
the above-mentioned property for inspectio,�urposes.
Signature (Owner/Agent)l ` Date
DING PERMIT' PERMIT#
DATE LUA_TION LOT �'� 9D' TRACT
/
JOB SITE
APN
ADDRESS fl3'Cr
SS 47-SJ.lvA 1..0,KWI ,
_ ..
OWNER
CONTRACTOR/DESIGNER/EN INEER
CWttADAY CO.1`aQPAtW
VA(T ATIO T-10. LS
174501 ITITI V£, 4106
9522 DC?NP+AIDDOit "RDI
zUTITR CA, 9T780
1.'C7(ffRAF_k'i tLLRY CA 97,35e
ilJj a��aSlgkt (;F.E 433; {
USE OF PERMIT
POOL X14DADR SPA
PGOUSPA. AIa39t.3WSh0*ARR=1PS SMALL 'HF, W PLA,.CZA't'
INSPECTION,
POOL AN DJOR 39'A 1%000100 LS
.. .:sax,-.. •
:7. s1 4 di) n.roA7.7. Aid` c'S.fZSsd.•k4d,L.r.i:.e,o,.},'V
FRINM ,173s�'i , SiWA4A#Y `
PLAN GklWX ria. 0 01-000-439-318 593.60
CON eTRUCx'f'IOR RE 101-000.118-000 $144.00
MECk A43ICAL, F'k1: -.. POM 101-00042.•1«000 $2,11.00
ELEC'f IC°A,L 11,99 .1 POOL i'0 e wtf0%,.s�, 40-J(tU, ': $45.00
LUMBrylo 1`' -It. -- POOL, A 01.000.419m00t0..
(� 1kLTJ?
(v
CI iY OF LA QUINTA "
FINANCE DEPT
€ XM-!'(5°iAAl;. i"JRSMei1::7Jt N A• M HAN C'£I1 E',Mt
$333.60
RECEIPT
DATE
BY
DATE FIN ALED
INSPECTOR
4.
r..
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain��
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
Z •,�Z
S�
PLUMBING APPROVALS
Gas Test
Electric Final
r
'haste Lines
Heater Final
'ater Piping
Plumbing Final
-imbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Finalao
�
57
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: