0303-128 (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
614611 C,53 9/3014;3
Date Signature of Contractor
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).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner '
WORKER'S COMPENSATIOkIJECLARATION
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
p rformance 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
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STAU IW- D Policy No. W-02 D10461.
(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 3.700 of the Labor
Code, I shaIll_fo thwith comply with those prov sions. f
Date: %� Applicant�y� ` I '
Warning: Failure to secure Workers' Compensation coverage is unlawf@I
� d
shall subject an employer to criminal penalties and civil fines up'to $100, In—
addition to the cost of compensation, damages as provided for in Section 16
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of. Building and afe
for a permit subject to the conditions and restrictions set .forth o '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, indemnity
& 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 inspectio�n-purposes.__,,�,'
Signature (Owner/Agent) w , %� ' ��'` -1, - Date -3
PERMIT # .
00�. `BUILDING
PERMIT
DATE t . . VALUATTION al I LOT l TRACT
JOB SITE
ADDRESS 80-470 V.M TALAMIb%. y
APN
OWNER
CONTRACTOR/ DESIGNER / EN INFER
TOTIL RRUNTERS BIC"
IWMITYRE. POOLS &I RPM
73.121 NULE WART NG 4100.
.®. 1:791
P.►ulvi 1 mwr CA 92260
L. QI-iI2, TA CA 92253
C'760)560-4585 CBVI 194.5
USE OF PERMIT
P00t. A�1tTD/OR WA
111. U ;y 'A_ ALAJKMWbAKX1ERS SHALL, B—Z IN rs .Ac:T A:i i'!SL> .F:l I EK, ,.
t1�91 3;s;i'TO1V. lspitil4jbilr�lTI3ICL+Lt'i;&D
POOL AN DIOR. SPA 15,000.00 LS
1:F1KnMX1.V C(Wlr QF C0 14htfR UCdTON
PILAW CNlXK, TER 101-000-.439-318 $105.30 '
saomwp.r3e: rim -'101-000-418-000 .. $162.00
MECHANICAL FEE '—POOL 1411�000421,000 52 ,0(1
81,FXTR.ICALFF—J?..2>.00L 302-000.•420-000 $45.0 '
PLUMi INQ FEE -- POOL.' 101 -0.00-41 9-000 $27,00
AR 1 1. •2003
TTY Ot~ LA QUINTA ,
FINANCE DEPT.
ST3BA 01 AT, CONUTRLTCY1011 A Pl;,r` bT CHWK
$363.30
LIE, l -PAU) ITZ2.1 '
$0100
_ TOTALPF_V�+.9 i°?C'�''�;_l�' L :4?t7�!:.1° O% .
RECEIPT
DATE
BY TE FI I PECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping i
•'.� PLUMBING APPROVALS
Gas
Electric Final
f 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
COMMENTS:
Final _.
Utility. Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
' G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)