0006-341 (RPL)LICENSED CONTRACTOR DECLARATION
J 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
656128:,. —_ ;i` CSr7- 10/31/7.
R
ntractor!ryr,� .:s n� �vwe jawoe � ` ate Slgnature of•Co� i-
`' ' 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, theproperty, 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:
O Thave 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.
(ct),I have -and will, maintain workers' compensation insurance, as required by
Sectiori''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'i"A'P9FUN D Policy No. N&O0-00061-63-00
(T.his 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 1. should become
subject to the workers' compensation provisions of Section 3700 of the Labor .
Code, I_shall forthwith comply with µthose pprovisions
Date: / %: /W Applicant l3 •, .r
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. till,
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
1 & 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 commericed 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) r-'� ` i %^^ 'Date
' BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
JOB SITE
APN
ADDRESS 78.4m vu.ArvuAwA
,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
17) Mawr DE C31-bENT
CALUKP.NIAP00U &SR"
JV0 BCOX,1716
74.725 3C» Di2MA4l.
LA Q1JJN T'A 04 92A53
PALM T?'I"'�MT CA 92260
,q
+4760,340-9000• C13L# 355
USE OF PERMIT
POOL .AND/014. ZPA
FOOL & S 04 ONLY.ALARM.". ARIJkR3 SHA LL HF, IN PLACE, .t X PRE
PLASTER INSPECTIONYOOL. &QUIT' 9RCLOSURE ISSNOT INCLUDED
1001,ANWO t SPA 14,300,00 LS
PE12Wf FRE IsL MMAJR..SC
PLAN G1IIsC`K FEIZ ;. 1,01-000-439-318 S10 UD
,
GO1JSi'TtUCTbOid lam); 101-000-18-000 ai52.Ofi
MECHANICAL FEZ-- POOL 101,000.421-000 $24,00
ELECTRICAL 1'RIC:AL FEE -. POOL 109-000-420-000 $45.0 .
_ PLUMB -I NO FEE •.- POOL, 101.000.419.000 $27.00
4 � �
MB MIAL CON9TRTI'C;I1.r!'N AND KMtAW C2 MCK
�3Ei3, 34
�3 PTt'G•J�AtiJ 1 u
$0.00
'r(Yf ►1 I'M�:r1�'��S'817E P?'CfW
�. 9
S&
RECEIPT 't?
DATE
BY+ {•
DATE FINA ED
INSPECTOR
X.
t,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE •INSPECTOR
BUILDING APPROVALS
`
MECHANICAL APPROVALS
F
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade..
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to W _p s'
F.A.U.
ti
Framing -
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
FansZ Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
,
'
. 4
Final
Final
BLOCKWALL APPROVALS
steel
'POOLS -SPAS `
X22 --
Set Backs 1
Electric Bond
Footings
.Main Drain
Bond Beam
Approval to Cover
Equipment Location
_ / — y U _
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
Final
Utility Notice (Perm)
'COMMENTS:
4