0010-065 (RPL)M
Ln
N
ON
U °)
Nt CL Q
Z
Lo aCr
0
0 J J
m<
O
� 0)
'It. Z
w O
Q"
J
r , LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of
Chapta� 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
d-721�I
Pate Signature of Contractor—
OWNER -BUILDER DECLARATION !r
r, , 1
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 undsr Section B&P.C. for this reason
Date Signature of Ownerr
WORKER'S COMPENSATION DECLARATION
I hereby affirm finder 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 Policy No.
CAL 10DT3f*, OYTTY FIND ll�t3tST+d3t$e�
(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. �y ��
Date: Applicant sv.a
- f :
Warning: Failure to secure Workers' Compensation coverage is,unlawful and
shall subject an employer to criminal penalties and civil fines up 6 $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/
t
Signature (Owner/Agent) %"` f - - Date r� ••�
BUILDING PERMIT PERMT#
DATE VALUATION LOT 0010- 011515 TRACT
JOB SITE !
APN
ADDRESS
p� /���{{ ((��' ��,, [t••��rr��+fmmrr��)� ��{{yy +*. yy��77�;DD��('{����'�
9-04`)`a.�Jt?I.Jl'W:{J.v�.R.'l�..Y�..0..^X.L.►.Y.61,
OWNER
CONTRACTOR/DESIGNER/ENGINEER
WMBASS
.V19.050 CAMITARA.DIU'4*'q
'7M1.50 t AW,1'L,103 h:Dll
�
JP, Cgw.u' Cris 92253
T ak ou i-"WrA CA V225-14
4~iU'Sti�fyl�' c�)�31?ff 3858
USE OF PERMIT
'POOL AND/O.R. SPA
P001, e SPA. 01+1L aN.Af..T. E DI P1,A 'i:' AT PRE
ENCLOSURE fS SCOT- FFS.T M, 1S>F D
THIS 'PkrwAw b j
k'C3tX AMOR VA 11 4?.C:dli# E'S
,
.. r
E9fC' MXffD +ti6:9b- f OF COi`IY1(" UCTION
f��t�1i0.4 b
PILAU CHECK PER 101-000-439�318 $74-0$
r c.D-N5TR,UCTt0R ft '1011 -000 -41S -t' O $1113.00 y,
MIXCkf AIMIt:AL7M -- POOL, 101-000-421 -000 SX00: .
&F<f ': TRICi4 L o., P007, 101 $imo0
MMBINO Mr. P0011 to .t���•4a���cly a , �
1 :V3 PRIF61?JID n"..3
X00
TOTAL nmmll PIMS purl" NOS'
RECEIPT
DATE
By
DATE FINALED
DATE
INSPECTOR
/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
s� 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
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test
Final
Gas Piping
l
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
Gas Piping."
Gas Test
Appliances
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)
r 41,111=`�C-_�
Fina
COMMENTS:
�f
_
F
rr 6- Do r- 00 ;)° I I 3'vs
�1ou5E
AJAA Cy
o� bl.uSo
M
f
.- a' fr- bo T t` t� a- j i C� P1
PO
of
//11 G {�
Pool.-
''.1`i '`j
�a
r
re n a� x 04 w.u-%,
• �L 1 ( ( 1 I 1 �„ A RE-INSPECTION FEE OF $30
WILL BE CHARGED IF THE A ROVED
Y t C'_ PLANS AND JOB CARD ARI NOT ON
THE SITE FOR A SCS DULED
INSPECTION. -i
wlktk o NO EXCEPTIO i
3 CITY OF
LA QUIN
BUILDING & SAFETY D
APPROVE-
FOR
PPROVE FOR CONSTRUCTION
161 1 / 9' 0 � � C/4r'i�F2?�i "" � DATE � /L v( BY.