0210-175 (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 # qry ryLi&c. Classy r Exp. Date
i� 110;
656]
43
D ri•�r� Signature of Contractor �� •f-
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).
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
performancb-of the work for which this permit is issued.
�( )%l, ,ave 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 :IPTATE COMP.}331.iw TI Policy No.
(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: f` •° Applicant— 4- Y
Warning: Failure to secure Workers' Compensatidh 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 y
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. i
2. Any permit issued as a result of this application becomes null and void if I
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/forinspection puTossees. t.
A. Signature (Owner/Agent) .�'.� l� / � � Date low, _v ..
BUILDING PERMIT PERMIT#
h''r
DATE VALUATIONk3 LOT . TRACTJOB
SITE
ADDRESS �c.�{� il"rY�'+v� 1A.�t�5�}�e
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T13 DESERT DEVELOPMENT,
CAT IP -OR -MA Pi OLS WAS CrOP K 1' CO
I
I'0 BOX 1716
136.1(10 AWN "#:1:E. 5.4
LA qAWA Cdr. :).225:3
ti" +) I.L.r'1, OA
�'�,CRE,
tb� nto0,p 5.
USE OF PERMIT
��001: S}'1.,131�� ja.td5 : 31 •��-i1��1,.lfE)'ivi?� T �d98 "
AcsA)_).ALAF4 i .y SHALk.:EY WI PizAt>`r.: AT I;R.'•p.LASTE
12dSI�L��"'f;'3CYIJ. 'E�Y3I�)��:'E�I�' �SI�KSP..�?5'QItL?'�at•+T' I2��.'L,ilr!£:11 .
POOL A?FWOR SPA 20,000,00 Ix
1r -SIM ,MID COST OF Cfi)1' &W.W.C111(3w
W.W0100
PLA9 CIYLCK US 101-000.439.318 $1131 5
CONSTRUCTION trUZ 101-000-41€3-000 $307.00
AdEC1-T.AMIC".AL� , E.- POOL 101-(?CI1-421 r-ODU 124.09
ta.LECTRICAkr M — POOL 101-000-4.20-000 $43.00
PLUM DING VBE ,•- POOL 101-000-419-1000 17100
=A -TOT _ 01T�.`� 1'.RtR-, fIUNP.H..D PLAK CHF X
IRS 'PR YEFS
$4373 5
NOW
CII; YX OF LA `IUINTA
FINANCE DEPT.
RECEIPT
DATE ,:
-/t',:
BY
a1
DATE FINALED
Z
INSPECT
C, ✓L:
!C
INSPECTION RECORD
OPERATION DATE I INSPECTOR OPERATION I DATE I 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
i 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
Set Backs Electric Bond
Footings Main Drain _ l
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)