0003-105 (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
33141.7 C53 048A 11201
"
Date ��"� Signature of Contractor "� f
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat 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
performance 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((qqAIM ryrry 77 yv���� Policy No. 00 rgS
(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 shall forthwith comply with those provisions.
Date: 1-i ' ' r, 2 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 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/Agemt—) f� I 1- '� Date
`J
BUILDING -PERMIT , OT
PERMITPERMI0"34415
E TRACT
JOB SITE
ADDRESS 78.975 NIA E1i1.r.,%1ViO APN T
y
OWNER CONTRACTOR / DESIGNER / ENGINEER
1::A rr SCHN1.&.)�R A; C`rI MTE ��e�Ayc-�•�a vf,"(Nm
fs { ViJ A. �I.;rl 4. k .�. ✓¢,. .. - t G V->Vt lr l�. )Y _ ..t ✓a.
78-9 i3 VIA VENTAAIA 74360 tiT'1..ARDO M)
LA QUINTA CA 92253 Ptlt..m DusE 'F CA 97260
(760)771-3293 C -'BL# 5302
USE OF PERMIT
itOOL & SPA.+i,5NLs- Hi,t�.eci�i i13Aiu�1��S �3It�i�i, iii; �?� P:t A01' AC
R L-P.LASTUt 114S4EECTION
VAt;UriT ON'
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ETNIAPEAiCOS Or' 01N'�r'.a1�R3 C".
i'T.a:.'A[IT l , E SWi1' NAR Y
PLAN CHEC KFE
101 -OW -439-318
$87.78
CONSTRUCTION F.W?
10#_-O O-4194TO
$1115,100
W CIA 1,11 ~'AL. -- MOL
101-000-42 i -W,0
s2K.f'rt1
;ti::t.F.l:.`%'wca f au -- TSL
t01-000-420-000
$dS.trC'
PLUfV1Bf1 461YH -- POOL
ILII -000-419-000$27.00
j
SStTBIT�t'l�:t,C't`).�tS`!'itilCl'Fi�N r1i+i:E7 �I,AiV riil C'�
LESS PR:F.?Te'!'1t7 FF1113S
TOTAL PC RMIT FEES DU ENONV
RECEIPT DATEBY ` DATE
INSPECTOR
x��"aJ'va"i.1v
$3183's
$0.w
:$.3.48.75
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
Insulation
Compressor
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
Steel
POOLS - SPAS
. 6 - (:.d-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Zp— 1- -
Underground Plbg. Test
r�
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
IF
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:
CONTRACTOR cannot assume re, , nsibility for r
• • - _
CGENERAL SPECIFICATIONS •
_ , . �.i:"` . ,• � ' damage to curbs, sidewalks; driveways, cement
SIZE
slabs, sewers, lawns, trees, fences. retaining
t,' t AREA PERIMETER Q
walls, sprinklers, telephone lines or shrubs.21
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Oc? C� When access is made through a riei boy='s DEPTH
roe it is undecsiood'that ycu, the owner TILE CHOICE SO. • r
have that nei hts6c ermission and assunne full RBB.
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r 'rs Y ^�{ ' t t 3 POOLS SPAS LANDSCAPE
74360 Velartlo Drive Wk. (760)773J293
j n +� - _ • t r - i Palm Desert. CA 92260 ' Pgr. (760) a33-7632
_ r {•4r L _ Stale Lic.p 331412 Fax (760) 773293