0401-064 (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 M
ty5b12e C'53 -MC ' 0�IICu
Date ri"� "b Signature of Contractor--
OWNER-BUILDER
ontractor 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
pegformance of the work for which this permit is issued.
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 ;S'L'ATE COR P9143ATI Policy No.. 046-6,168-2044
(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 hall forthwith comply with those provisions.
Date: "',_ - ., is Applicant—
Warning:
pplicant 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 permitrto 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 forinspectionpurp7--irV
Signature (Owner/Agent) !� y Date
• BUILDINGPERMIT _ PERMIT /t
DATE VALUATION LOTTRACT
JOB SITE
APN
ADDRESS MOW VLA. VALKROSA
- -
OWNER •
CONTRACTOR/DESIGNER/EN INEER
70111 I3,Rr.J`.0-M% r IVIC
CALWONUITA P0 OLS , 0XI C1 'OP KkW CC
-7^^ll3-12TTlry�'��ZCi�)v�niif.�iM�' 0160
.86-/1,o�aC9�yf��Vy��TUE- 54
p ryry y�
PAIM A -.:A AW.—Rl' CA 92260
p yy
CPV.d9/_S4r1 J.r,4 A �.a.F`n. 1922 6
(760393-922. C;EiW 00355
USE OF PERMIT
POOL ANia OIZ
PDOLJ�'i3JA, 3 L, A- V B1,OCK'WALL, C' TY
'1.AAtF3Alti3, h �. ,rTlt 13 AI T1•:R,�' SHALL DF IN f'1.k CE AT F!R&P.U.STER
S V7, WALL 349 LF
P001, A.30DIOR, SPA 3'1,9.36.60 LS
.iL:STMU'IND COST OF a,'.OM�'�`tiU+GTION
PLA314 CHECK FEE 101-,00",39-318 SIX70
CCIAWSTRUG"".t' ON F FIZ 101-000-418-000 $1198.00
M9CHM11Cia1.. I~M - POOL - 101-400.421 --%O 9i IX*
F,L ?C`1IUr_Ai FZ1 .•. F'C'OL 102-000-420.000 013
PL>wTMBINO FrI , - POOL 101-000-419-000 ��.��►
SIM-TOTIAL COW. iR1Ic tf'OKAM) CBECIC
$422.70
1013 PRE -PAD PLL
ADM
p.&-- 'AL
Pig x�1*� � 1+ �3�.S DUE NOW
S422,70
JAN 121004
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
R.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
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
?
Underground Electric
J _
Underground Plbg. Test
L 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
Final
Utility Notice (Perm)
COMMENTS: