0012-052 (RPL)LICENSED CONTRACTOR DECLARATION '
I hereby affirm under penalty of perjury that•1 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.
Ljeense # .' Lic. Class Exp. Date
771
pate/ ��� ��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 isnot 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
performance of the work for which this permit is issued.
(Y) 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 Policy NO: «'
STATE FUND
(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 I should become
Subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sDall�forthwith comply with.those provisions
Date: Xie f %��y Applicant - �� J�. fir.` ' • �~
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 appl caton 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:; '
Signature (Owner/Agent)"x( ..'_ sl ' Date
BUILDING PERMIT.'PERMIT #
DATE �qJ �� VALUATION LOT 0012"W2. TRACT .
JOB SITE
APN
ADDRESS]^: WA+w.YF.�A� CaL"Y,
OWNER `
CONTRACTOR / DESIGNER / ENGINEER
M" C1001JIM
FlURNEG11411 WC
C.'.tT=_
?'',li8CO. RIM WAT:Li;3'C:i:DR.WL
LAQUK A CA 92,253
T-,ALM3 ESPIRT CA 92260
34,0-3165. 65.. ' ClLO 6276
,
USE OF PERMIT
TjOOL PITD/ak VA
�S
l'OOL O -NL Y(T;O t'1P:E TIZR) IALAILfa t46ARiR1.12S SI-IAI,.I, Oki 1Af PI.AC A'F
PRE PI ASTER .ANSPEC".T;0H. Pool, EQUIPMfS'4d'1 ENC11C:►aUR& 1-9 140T
ENCLYiISM IN THIS PERMIT
r
Pool, ANDJOR SPA 211,500.00 Ila
- r,.b iMA''3?:L? CONT OF C;'O:t`TWJrRUL"iICaN
211500.00 . .
:PLAN CHECK F9E � 16i<f3vv�SAuS]� a146.2�
CONSTRUCTION FEE
KLECTRICAL 'AFM -- POOL 1101-00.0420-000 $45.00 .
P, iTl>Ifi TNU F.E.R POP11. 101.-00"19-000
:fB-TOI AL COk3-MUCM09AW) PLAN CITLEX-11r.
$ 143.25
LES3 TYRE -PAD M
$01.40
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
r2:�tj3.
. . .
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
t >
Final
PLUMBING APPROVALS
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
O t CQ
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)