0006-108 (RPL)LICENSED *CONTRACTOR DECLARATION
Ihereby 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 '
574127' A, _ - A8/3 I lit
Date Signature of Contractor'
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).
O I am exempt under Section B&P.C, for this reason
Date Signature. of Owner-
WORKER'S COMPENSATION DECLARATION
l hereby, affirm..uncler penalty of perjury. one. of the following declarations:
O 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 6y
Section 3700 of theLabor Code, for the performance: of, the. work',for which this
permit is issued. My. workers' 'compensation'insurance carrier. &. policy no, are:
Carrier Policy No.
STAn V1,fH6, R4b�9% A9i 34
(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,
(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, 1 shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is:unlawful and
shall subject an ;employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation,:damages as provided for in Section 3706
of the Labor Code, interestand attorney's fees.
IMPORTANT Application is` hereby made to the.Director of Building and Safety
for a_ permit subject to the conditions and restrictions; set forth • on his
application.
1. Each person upon whose behalf, this application'is made'& each person at
whose request and for whose benefit work is performed under. or pursuant to
any permit issued as a result of this.applicaton.agrees to; & shall, indemnify
& hold harmless the City of La Quinta, its off icers,.agents and -employees.
2. Any permit issued as a result ofthis application becomes null,and void if
work is .not commenced within '1:80days from date of issuance of -such
permit, or cessation of work for 180 days will subject permit to cancellation:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State Jaws relating to. the building
constructionc and hereby authorize representatives of this City to enter upon
the. above- mentioned property for inspection purposes..,
Signature (Owner/Agent) Date
BUILDING PERMIT PERMITN
DATE VALUATION ' OW6�• M TRACT
QQ+yy �•'LOT
JOB SITE
APN
ADDRESS 79-37 C�D4,tE
OWNER
CONTRACTOR / DESIGNER / EN (NEER
J'AC`K I3XAt°�%E Fl � �.
s Fw I ODS )H CC►MPaucrION IATA".
79.733 C'' T -E- rA VE'R17E
730- i i COMTRY MIUD _R , RMIE F4
LA QTJU4iA CA-. 92253
PALM RESER . ' OA 92260
-(764)346.4032 0130 1044 .
USE OF PERMIT
POOL ANTS/Oh. SPA
P0L &S,PA, OWL - ALA RM ARM iM MULL i3E N I✓ACEAT
PRE-PLAISTER TN$PEC:TION. 01.-OCK IVALI, FOR i:QUIPMZNT FWC110SURE
IS Nat INCLVIDED CN THIS F'EF2MIT
VALUATION 2.060.09 z.3
:t wrimAxer.D con or C'()1tf mo :f: om
234463.013
PtiaRWf FEE �3"iY.A09"Y
�
PiANN C>~MCK FEL 101 -000-439a,31
COINS 'RUICTION YFZ 101 ^c>a t19-QQfl
M C-.f•1MICAL PER -- POOL 101.000.421-000 $24,00
M,ZC TRIt°„Al, F1F�t.�. -,-, P00- L .101-0004-20-000 $0.00 .
PLL:tMBIHO VUE - POOL 10I-000.419.000 127,00
9•t7i�,-t`CY1iAL OONY1RUCTION AND PLAN C5 -W -X
$496.95
LESS PRE -PAID MS
$0.00
TOI.AIUMPRVAI IYM 1 VE
S496SPS,
I f
-
RECEIPT
DATE
BjYI1
DATE FINALED
INSPECTOR
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
[o'
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
Pool Cover
Sewer Connection
EncapsulationLoc."
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: