0010-238 (RPL)LICENSED CONTRACTOR DECLARATION
under penalty of .perjury that I am licensed under provisions of
I here y a IF
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
Date f'" �` r'' Signature of Contractor f
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 I
.
( ) 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).
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 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.
O 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 Policy No.
STATE FUND
(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, I shall forthwith comply with those provisions. A
Date:.,e- r. Applicant
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 Safety
for a permit subject to the conditions and restrictions set forth on his
application: 04
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 for inspection purposes.
Signature (Owner/Agent) Date / r ' • n
BUILDING PERMIT PERMIT #
pp/f
DAT Erf J,r�; , . } VALUATION LOT'TRACT
(
{Y
s' xp
JOB SITE
APN
ADDRESS
4t"77 V19FA VALOMNO
OWNER
CONTRACTOR / DESIGNER / EN (NEER
I
ty 17
13 & S.PA 3
C'„q:*iI�►'�'C�:i(�•
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� � 131116
pSLy�lt�y''00,
-7253
1Ag9YW!A CyA 92253
PAIX.1YESHI:x ;CA 9,2260
€Ci9l�o'rt3�k' C9 355 . .
USE OF PERMIT
POC:fE, .ANDJOR 9PA s
SHALL BE IM i
t'°1t? OR' jM' PRE PLASTER INSPEC T luNY00,1 FQU.1P1'e#"*T P1R10suRy, 1F, '
POO7rAt DIORSPA 14800:99 W"
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ID C0911 OF CONSMUCTION
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PLO CBEC'l"s els: 3tl3=�t10�1N�+•�YL3 ��1�,4fl
r",URSa'RUCT1014 iIrEE 101-O0-••.118-000 �lac.oc�
MECflAfifMA3, iE,i? —POOL OL 01.000.42.1.000 $24100
EI., 'I";St.iLAL ITFS an POOL 101 -000-420.0610 $43.00
PLtX6tiBPRO Fes: M. POOL 101-000-419-000 $27.00
q, fR- X'i` J1U, CONSTR:C1CIT169 AND X?%AWCUAR6;vIS
3 ip3.00
2 g 2000 �'C5'�., .,PTI..Rwr VES DAM Now
93.00
CT
RECEIPT_— , "' ]DATE
i
By Ir i
DATE•FINALED . y�
INSPECT �
I � I., ... ' I l
Final
I ELECTRICAL APPROVALS I
Tema. Power Pole -
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice (Perm) !
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Footings
Underground Ducts
Forms & Footings
Bond Beam
Ducts -
Slab Grade
Return Air
Steel
+ Final
Combustion Air
Roof Deck
I PLUMBING APPROVALS
Exhaust Fans
O.K. to Wrap
Electric Final
F.A.U.
Framing
Heater Final
Compressor
Insulation
Plumbing Final
Vents
Fireplace P.L.
Equipment Enclosure
Grills
Fireplace T.O.
O.K. for Finish Plaster
Fans & Controls
Party Wail Insulation
Pool Cover
Encapsulation/a
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
I ELECTRICAL APPROVALS I
Tema. Power Pole -
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice (Perm) !
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
+ Final
Underground Electric
Underground Pibg. Test
Gas Piping
_
I PLUMBING APPROVALS
Gas Test
C'
Electric Final
_
Waste Lines
Heater Final
_
Water Piping _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation/a
_
(—
Gas Test
Appliances
Final
COMMENTS:
Final
I ELECTRICAL APPROVALS I
Tema. Power Pole -
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice (Perm) !