9711-075 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter.9 (cbmmencing 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
6561df; C53 ' 10+`31f98
/'
Date - Ci
Z/ ignature of Contractor
V
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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
calx (Soc. 7044; Bucinocc & Profoocionnlo Codo):
( ) 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 z` 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. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This sect on'ne d no be completed if the permit valuation iQ617579-96 1 0 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.
DaterApplicant X f
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 applicator 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 iso
correct. I agree to comply with all1City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon.
the above-mentioned property for iinspection.purposes.
Signature (Owner/Agent) //� i Datef
BUILDINGPERMIT
(�r=1
PERMIT# COy/NTTROL#4
rYi`.,L�I/�IYII
DATE VALUATION
LOT 97i�1•�i�is TRACT
G
6 28.6
11J�SJq'1
516,{NNbAt1
JOB SITE
ADDRESS `
APN
ERIA
OWNER _r , ^�
`7U(
CONTRACTOR / DESIGNER / ENGINEER
kSL LAND 111}1
CALIFORNIA POOLS & SPAS
79-95; PGA WF91' BLVtDl
74-725 .fONI C)RJVE, #A
LAQUMA
CFS 92253
CALy92260
fPA�/L�AyZ,�i�JE�SyEER't'
00
w" 35S
uoc or rrnmIT
a
POOL SPA AND REQ
Jy.
POOL, ANIXOR SPA. K000 .00 1.S
,
WYlt1XfED
COIST ()F CON ST.RuernoN
9.b,11l111,tlll
P1 RX11T F'E'E SUlWhIARY
14t.AW CHECK FEE
101-000.439-31.8 1.13
CONSTRU( fION FEB
101-000.115.000 3I r 100
MECHANICAL FEE -- POOL
101 -000 -421 -OW $`24.tttD
EL>^ CTR1 : AL :PEE --FOOL
101-000-120-000 � $45,01
PLUMBING F ER -- POOL
10.1-000-41.91000
DAID
NOV 2 5 199
SC.fI3-'CC3'm CQN�:, rP L►C°I'1(,m ;hNNL)L_AN3C HECK
;$379�11i�
TOTAL PERivfl'1i FEES DUE NOW
$378.15
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I DATE I INSPECTOR
BUILDING APPROVALS
-Z,nt Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Lines
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underaround Electric
POOLS - SPAS
Final I I
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
I Pool Cover
COMMENTS:
Final
I ELECTRICAL APPROVALS
TemD. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
`Utility Notice