0008-262 (RPL)LICENSED CONTRACTOR DECLARATION
I, hereby 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 # L'ic'Class Exp. Date' t
�$903i7 CS3C &Z9,,` E3 / jf06/30W
Date/� �`' ' Signature'of Contractor ` �Yt "6 +,Oyr- �•
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am.exernpt 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 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'.
�C) 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:
Carver Policy No.
STfg til 14D 2.19:00 UNITStr20130
(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 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' compensationprovisionsof Se tion 3700 of the Labor
Code, I shall,fo hwith comply �with those provi ion's. ,
Date: /" "� Applicanttrrx• ,
Warning: Failure to secure Workers' Compensation coverage i ` nlawful 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 ae'
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator 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 property or inspection purposes. w
Signature (Owner/Agent) ✓ Datef
BUILDING PERMIT PERMIT# "
DATE�VALUATION LOT TRACT
fj-
�� �r��i�>r,� • .
JOB SITE
APN
ADDRESS
^-
78.9 WA V.F.1ITAKA
-
OWNER
CONTRACTOR/DESIGNER/EN INEER .-
A�!/M VriF'Z AL
MA111I2AL,�h"�W0.
78.953 VIA V.-NTANA
73-960I3f%7WAY 17 I MM 3
LAt LTW,CA CA X92253
:PA:L14I) • SIMT CA 92260
f
('I60�S�iIi^ti'726 (�AWP 5220
USE OF PERMIT
PQQ.L lir YQR WA
POOI. & SPA ONLY -AI AIv'MS/B.APMERS SHALL IIF IN PLACE AT t
:t
P�MASTER. INSPECT rc'?�r.POOL, EQUIPM50T i:NG 'ttRE IS NOT
I14MUDW IN THIS PERMIT _
POOL AND/QR SPA 317,0100.00 LIS
r
� • ;
M:3"1' 1M�C�.,3? COST Ors CC%NS t7E UC 110H
17,000:00 ,
7?ERWr14TE SUMMARY
� ••
PLAN C1• ZCIa FT. E 101.000-439.3118
ICONSTRUC:TIAN FEE 101-•000-418-000 $180.00
NIPCHANICA L FEt, •- POOL 701000-+121=000 $24.00
ELECTRICAL FEE'- • POOL 101.000--420-000 S45;00
PLUMD114 i ME • POOL. 101-000.419.000 $27.00
y'
90:8-1'07°AL COMMiI'C:"IIO AN7 Px.,AA7
IM9 MR -PAID FRY01
;£0.06
$N
RECEIPT t {
DATE
6Y
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
' BUILDING APPROVALS
MECHANICAL APPROVALS
'Set Backs
Underground Ducts
Forms & Footings
Ducts
Siab 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
el -
Set Backs
Electric Bond
=l��4*1
_Ale
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
Sewer Connection
Pool Cover
Encapsulation
_! _
Gas Piping
Gas Test
Appliances
Final�
Z f
/
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)