9804-143 (RPL)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of •-
ttapter 9 (commencing with Section 7000) of Division 3 of the Business and
Profgssionals Code, and my License is in�full force and effect.
License # Lic. Class Exp: Date
} " ¢14597 C3 313099
ate YA V Signature of Contractor" e r" d ° •"
L'. 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 isnot 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).
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 r
(j�) 'I have and will ,maintain workers' compensation Insurance, as required by
Section 3706 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,FM4D . iQ1362-1r
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the work for which this permit is issued,
I shall riot 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 4he•Labor
de, j fshall.forthwith comply with those. rovj
isioo
Date: <�ri • ` Applicant-
Warning:
pplicant `«- - . , ✓ �.R,�✓�:''
ode,
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., p
IMPORTANT Application is hereby made to the Director of Building and Safety 9
for a• permit subject Ao 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.
(.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 Ill
construction, and.hereby authorize representatives of this City to enter upon
thefabove-mentioned property for inspection purposes. . /x
VSignature (Owner/Agent) -' � Date
7
BUILDING PERMIT :. PERMIT CONTROL#
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DATE r VALUATION LOT 9804-143 TRACT ®_y
'
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JOB SITE -
ADDRESS
APN _ +
'
7&W VIA MEL41011!
OWNER
CONTRACTOR/DESIGNER/ENGINEER
NORMAN -1 GORE : .. . ' ^ . "
SAN WAN POOLS c&• SPAIS"
78-840 VIA "Ni`ELODIA
72/135 CHOLLA OR
LA QUINTA CA 92253
PAL:A1 Iil"s'S E1tT OA. 92260
'76 CUL -0 4796 .
USE OF PERMIT
A ONLY, AI.AidWAB'_AMi - R;S A'R':ts TO BE- OPERATIONAL PRIOR TO '
8N -CAP. PR.E<'PLAS1`EER (NSPF.C,!'i0N
POOL ANDIOtt SPA lt);0f30.00LS:
�—
' I INAi',ED COST OF C~(MeI UC'�It N
349�6tdit�,4(lt.
PM. 1f T FEE SUNIM RY
PLAN CHECK l%EE. 101-000-439-31s 5
GOi+rs'1 izlJGz lOt+f:� 101-0W418-000 .. $117.00
.
ALFEE -- PSI::.;101-000-421-000 ` $1.00
I�( EC UCAL rte; 'S: OQ W-006-430-000'
PLUNI'SINQ FRI.--;POOL; 101 00(1419-000. $27,00
'•.
�'• i. �Q.
'10OX'AL Ol�f�f LC ETON AtYD:EyLnN CHECK
APR :: , .: LESS. MC-PAIn ,FEES
50.00
,
>l 79981.
TOTAL PERMIT FEES DU C.I ONV .
'�B V Qlwly-r�
RECEIPT -
DATE
BY'
DATE FINALED .. ^
INSPECTOR 17.
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INSPECTION RECORD
t OPERATION
D'
i
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
POOLS - SPAS
Steel
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
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
l
Final
Utitky Notice (Perm)
COMMENTS:
CITY orN
BVI INGC3i�k� P ME
NT
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SUBJ F 11. 'c.9 -P E R
AN ALL. APPL AB., ' Vo'CcS
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