9905-136 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm uride rr. penalty of perjury that I am licensed under provisions of
Che;)ter 9 (commenc ►fig with Section 7000) of Division 3 of the Business and
Professionals Co
nd my License is in full force and effect.
s 'License# �.,ji* Lic. Class Exp. Date
Sl1 7 A 1 c1S13i%l:r�
/ (... Y e-i•..s'-nil f �^"-.
�0 k/_ `'X Signature of Contractor
'ter'`'.'
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 he affirm under penalty of perjury one of the following declarations:
() L 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
S ce tion 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 Policy No. .
VATR VIM)
(This section need not be completed if the permit valuation is for $100.00 or. less).
'() 1 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
sut to the workers' compensation provisions of Section 3700 of the.Labor
Ce.de, I shall forthwith comply -with /thosee yiervisions.
afl
I,D�at ,r Applict ^� f ., � � "� ✓ ?�f` . i .w9 . Y i.,_...
Warning: Failure to secure Workers' Compensation coverage is unlawful and '
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of `the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a',permit subject. to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2,. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or.cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the ab vo e -mentioned property for -inspection purposes. !r-
,� A�'+'s✓tee i�f s •"
IS'I'gnature (Owner/Agent)
BUILDING PERMIT-.- PERM T#
N
M.
DATE VALUATION LOT TRACT
/ �17,4d1Q 61� ••
JOB SITE�D
ADDRESS '' 799LI).`#i� V:e(: CORIA 13,R
APN
N.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Rt: LLANOr r. r t A
i L L.{• O Cf!LL-Ax
+`"7y"�r r > a+ r'n r R. ,�,.. ti:';
♦:Mr 6.3;. L�d,/�.:f.,il.'a UlJ�4.4j�h1„jiy l ��5'•
74-030 WC'AM4.:DR
7301.1 Ci7UN'MYC1,'US M., SU111 i4
1.A Cji.7EXrA C.A. 02-25-1
RALM DI S)r.CtT CA 42264
(76Q)3-4&.40:.%2 CRU 1444•
USE OF PERMIT
POOL t1Ni3/c:1R SPA
�
�aL''3-ait►.ii �u
POOL t'�'I"IGA SPA 1.7,+4x` 0.0 LS
ESTIMATIEW h:ONT OF COiR7STRUC710N
17,40().0$
PERMIT r'K. I` SUMMARY
f%l;ANCH CKM4 101-,000-439315 51..12.85
(1X. 81TP7;r(1,TXt N FFF 101.0 -W-4484)00 E ;fEo
aX41CtlatihT(C/`•5;t..F,8`2 -- MAI- 1.411-00042, -0!)0 ;524.00
CzC E.crj icAL T t - . Poc)L 100 df0)�fy313�•�l2tia1OO $4:'M
PLUNIBi 0 FLE POOL 101.00-419t0p0 $a7nt t1
SIA-1-11TYI,7AL CONSTRUCTION ANY) `LAN CHECK
$40.7.85
LESS PRE—,i'.dN1:L'1FEES
$0.00
TO i. XIAMRMIT FUS. f U(±: "VcyW
$407,85
A
g • r°'a
RECEIPT
DATE
BYf
DATE FINALED
INSPECTOR
.- .
i
J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Formc, & 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 8 Controls
Party Wali 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
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)