0010-273 (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
Date h2* `0.0 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, 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
()
lam exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATIONr""^`'xr"-r
M
F<•`"
I hereby affirm under penalty of perjury one. of the following. declarations:
O I have and will maintain a certificateof 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.. '
( ).al 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 A 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' compensationprovisions ,.of Section 3700 of the Labor
Code, I shall forthwith comply with those p ovisions
f Date: /,,,4? A 61P Applicant r F..r r iil.dt'6✓
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.
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 properfy�for instection purposes.
Signature (Owner/Agent)tf �� ``^t — Date !'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
WI3C.i.ppge
49-5911 0
OWNER
a
CONTRACTOR / DESIGNER / EN (NEER
YO BOX 1. ;16
'14-725 JONI ;�C�1r.CV'E, 4A
i ,A C)MI°D'. A CA 92253
PALM DEMAT , CA 92260
USE OF PERMIT
A�OC�ai2.g1t��3r)J�"f1lt9?A�
AS9yAL�p�w-j�i4pr���city9fy rpray 1 A/� A c�t��
POOL A SPA ONL ifa.��aR?S18at�[PLCaFi.81.1 ERS S S6SI L UE'W. PLACCE AT i'.Y� E t
EC°tt3T'4;MEN'f, ENCLOSURE 10 4aP PWCULYDED
:'Ris PRIMIT
F00L,,1NND/C;3i3.'RPA 3 ,3RU,41 1.«J
ES'� Y1 IED COST OF CON'rVER01 m17CO r
1518W.00
PW) CHECK R11Y, 101.000.4.39-318 %JiM3
0"11INS a"/ti i¢;"> 1014 RIK 10.1-000-=a I -Cabo $171.00
W1,o 0-FWA1'(CKL 'Z -- P00I 101 r 000-421 -000 VA
G:M' RICA:€. ME. - POOL ; Oi—' 000-+r'20-000 :45.<Jit
` .010.1q8TI R TC3110)'TAW3 P LAIR 0MICK
$378.15
. 3YUM IMINKU ,�y�YS J.+0.% NOW
RECEIPT
DATE �c ¢¢
B� P.
DATE FINALED
INSPECTOR
INSPECTION RECORD
F 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 - ant. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Footings
Electric Bond
Main Drain
; /s��
_ 0
Bond Beam
Approval to Cover
Equipment Location
Final
Underground Electric
Underground Plbg. Test
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
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
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)