0309-135 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— Chapter 9 (commencing with. Section 7000) of Division 3 of the, Business and
04 W Professionals Code, and my License is in full force and effect.
O =) C) License # Lic. Class Exp. Date
r` w 8410 680 C-53 1 Cs�'3112(
C) Z r "D tae `Signature of Contractor 0.
(0 "Zoold
J U C:) OWNER -BUILDER DECLARATION n'~
LI W I hereby affirm under penalty of perjury'that I am exempt from the Contractor's
~ a License Law for the following reason:
Z ( ) 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).
Cf) O I am exempt under Section B&P.C. for this reason
C; 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 MPT.N ,EJ) SU87 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. t
Date:j pF . 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, 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.
j
Sign ure (Owner/Agent)' 11 :.Date !� f ! D i v
BUILDING PERMIT PERMIT#
033
DATE _ VALUATION LOT TRACT
��� 4�3.iBt31
}APN
JOB SITE ! "
ADDRESS 41-330 V WA MWI..LA • i', � .
OWNER
CONTRACTOR / DESIGNER / EN (NEER
MW?, . JT01 �'A JBR" fiXT ..
R"F:i+ffiRANDr P00YJ eAN1; 03 AS
49-330 VWTA]P_.hTMS2,A,
4880M01,72�'AW COVE DID !V.G.94
Safi QLilk� aA CA 9.2253
i3
INDIAW tMPLLS CA 922141
(760)345.1376 MLO 6.697
USE OF PERMIT
,POOL ANDIOR SPA
POOUSPA.,RLAWSM.A.R21M SrTAL;. BEN PLACE PP'.�OR TO
PRF.1'`LASTER INSPECTIOA1.
POOL ANWOR SPA l4,R1li9,09 Lr
.. CS1�'1;' OF C�?.�T�"�` UTC�ON,
• :1.�,�2•(i+.9IfiA
.
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' T.feS.�i1VYU, Af.,�R'•d'r h1m. v.:rB.Ltl•7 _
PLAN C'HR.0-.FEE, .. 101-000.439.318 $169.3.0
COMS'TRUCTI N IME- . MY -'a06-418-000 $153.60
MWHANICAL FER,. -- 'I' 3t1i: ' 10 1-000-421-000, SUM
ELZCTRJCAl. PRP a.:17001.. 01-00042€2.000 ` �tS.StO
PLUMBRIO TME .•`POOL ... 1'O3•.:r 004419.000
_ 200.3..
NT0TproL
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a.
RECEIPT
DATE
DATE FINALED
INSPECTOR
//1
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
7,
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
7. Z
Equipment Location
Underground Electric
✓ _ 013
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
Encapsulation
J -
Gas Piping
Gas Test
Appliances
Final.71-77—Q
3
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:
12
JUti HUUKESS_�q ams �� � PERMIT NUMBER OWNER f��GrAr� > BUILDER 6E/r RA416 rOoLS I c�Pf J11
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this fob. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be corn Inter by applicant "On File" is not table
Trade./ Classification
Contractor
P
State Coritractor's License
an accep response.
Workers Compensation Insurance
City Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
'(xx/xx/xz)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
CONCRETE (C-8)
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M [� ��
53 20 =0 �'3 �7
•
I� t7i '�
FRAMING (C 5)
�£ 1`
/,
�-! �' J 8 %
t'✓ '% `�=�
S��/o
STRUCT. STEEL (.C-51)
00'2-�`f `7'7
6r n:�
0�7�
3i o.
MASONRY (C-29)
PLUMBING (C -36).i
ko
)013110,11
S; PTk-
`
by or a 4
06�/�%
LATH; PLASTER (C-35) .
DRYWALL (C-9)
HVAC (C-20)''
ELECTRICAL: (C-1 0)
0?��%
o 0�
ROOFING (C-39):..'
SHEET METAL (C43)
FLOORING (G15)
GLAZING
INSULATION. (.G2)
SEWAGE pISP: (C
PAINTING .(C-33).:
CERAMIC::TIL'E (C -54)'z..*.
CABINETS (C-6) ..
FENCING (C=
LANDSCAPING (C 27):;>::'
off' % b --f t
POOL (C 53)
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