0101-092 (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 Divisi6n1316f the,Business and
P- ofessi;I%kls- ode, and my License is in full forceiand`effect.
L'icense,# Lic. Class Exp. Date
484 498, 3.5 C33 i 117P, I
Date .' "" L'" f Signature of Contractor
'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 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. Myworkers' compensation insurance carrier & policy no. are:
Carrier 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: .6 :02 Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth onis
application. a% T!
1. Each person upon whose behalf this application is made & each person'at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, •indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null acid void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have. read this application and state that the above information is
correct. -I agree to comply with all City, and State laws relating to the building
construction, and hereby. authorize representatives of.this City to enter upon
the above-mentioned property for inspection purposes. •
Signature (Owner/Agent) Y w. �' _ �� %� s r r-<a`Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
4151111040 T2 23995-8
JOB SITEi
APN
ADDRESS `
r
}ice p�� g�� ^`; I! t
'8`',..'i�dl�°P•'VY,AAt..L!cd:�'li,�ii.at'.J
_ ..
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MiWER0RA°Ai H
T F)]t�JC LIS MD COiiS�D'1R BCW d EON
784905 WAKME19,1D
gI?U/'tk'i:�t��'�'�/ti„'
LA QVWTA .- OA, 9.22,53
r%.�"�.,M TSF. Mlr CAS 92261
(76())5684963 01111 if 725
USE OF PERMIT
fL til .i��OI , ffpA
P001, rfi SI?',AOTIZbY'=r`.'�I�.�itE�:sfk�iki'IP.tCaFt.:i LPit3LL RIE, IN P1,ACICA11 PR`S
PLASTER INSI I i ION,P00w EQUIPMENT ENC:3.OSVIRE IS NOT fHC1,ilDp}D
IN THIS PIFIRMIT
POO:£,ANWOR SPA L3
:ri51'$'n{dN1<'ED ermarr or C."-£}nwrRI[R't:.g°!.ON
1510MOD .
1114.Q4 CHRICY, LIRY, 1.01-•01*439318 5145.30
C,`ONS M UC.'d 1014 PLO, 101-000.419-000 $162.00
M3,,t>H(i'5ARr;AL :9'`_X -- POOL, 101-000.421-000 $?4, ►fl
XwLI`i "FRRRCAL MINE — 101-000-420-000 so.00
Y
AN
UU01
sua-- aO„ Play cal -am
$363.30
n �
y,��• ry,�t
DUE
�!�L TA IL, PEg'45!`.ddt•�Vlf. SDh.E.A�Ta0!fY
�. i'G:beJi..�:IF.•
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
T 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
r
Final
Final
Steel
Electric Bond
Main Drain
POOLS - SPAS
- -
I [
Z 1_�
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Approval to Cover
'Equipment Location
Final
PLUMBING APPROVALS
Underground Electric
Underground Pibg. Test
Gas Piping
Gas Test
Electric Final
\
2
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
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)
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
*a NO EXCEPTIONS!
Purrfect Construction
CITY OF LA QUINTA,
BUILDING & SAFETY DEI,T.
.APPROVED
FOR CONSTRUCTION
DATE2'3 �t BY
Illtkioc dl
damage_ewalks. driveways. cement 51ZE
slabs- ley �es.tences. retaining ARF
wils.spdnklem teleRboneDoes a_shn�s.
Whe access is made through a neiahbot DFM
pM�v it is understalA mat you, the owner. LE,
have that neiahbor's permission and assumeld L
msaonslbili4c. GOP!
DATE signature I
'001
-- -..-. — Pum)
l�+PL MUT
ITC3i_HP e
TER STA
EI�RNOVER .. - l
SKIMMER MOD&�:,:_
CHECK VALVE
GASliN�BY __ � FT�:�I
POOL -LIGHT 400 ACL
FI FMRICAL F1Y_
DECKTYPESTEP
051,
SPA SPECS.
DFSIaNER CZE "�: RAISED
�VJCJ : , UTE 100 WATTS
i I LIMI. SEATS 22' 7'
� 5 `� - �-Pc ✓� DATE DAMWA" ' X Ff.
\ SPILLWAY SIZE, - _ " X _
H ry I sum SP�AY _.,._OPEN.
Addmm
Cft
P.O. Box 1524 • Paim: Dese , CA 92260 • .(619) 568-4963
?.i-
.'BUILDING DEPARTMENT:
CITY OF LA QUINTA
OFFICE: (760) 777-7012 INSPECTION REQUESTS: (760) 777-7153
F TO: DATE: i I CJI
ADDRESS: �` ��1 Y—\\/ r�—
CORRECTION NOTICE
INSPECTION:= P� PERMIT NO.: ~
1 /max `ice G, a-, s ay �E '�� �`� *z-r—
.Inspector