0003-013 (POOL) LICENSED CONTRACTOR DECLARATIONPERMIT#
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I hereby affirm under penalty of perjury that I am licensed under provisions of ) 3 -6 BUILDING PERMIT 0003-0113
I- Chapter 9(commencing with Section 7000) of Division 3 of the Business andDATE VALUATION >l�, y,(}p LOT TRACT 7.87!)7
C%`1W Professionals Code,and my License is in full force and effect.
O M License# Lic.Class "-"^, Exp.Datta
JOB SITE
r` LO 09945 I3 J lei�O1��1 ADDRESS APN 769-460-008
' W f
Z Date Signature of Contractor OWNER CONTRACTOR/DESIGNER/ENGINEER
O o -- RUT t 10,Mt:lk,'kl,c:. RTt-INVES 1'Mr1"US,!NC
OWNER-BUILDER DECLARATION
—J U coo P.13 ii+ikfil4 I k�S .LAi1L'I:scSIT 'DRIVE
W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason: 1AQU111�)'I'A CA 92253 �`H0hNIX AY, 8S 034
X7.2
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (S><1`1}�.. �� C;R],f� d,�
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed K01.AND/0It.SPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
exempt under Section B&P.C.for this reason POOL&SPA ONLY-ALARMS111AR F"E S Si-b%LL BE 11v rLAiT.AT PRU
LO t'1."TER 1NS1r1 k rJQN
O N Date Signature of Owner
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IL Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
Lo N O O 1 have and will maintain a certificate of consent to self-insure for workers' POOL AI`jLfiGld:hA 10,0W,00 L3
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q ) l'have and will maintain workers'compensation insurance,as required by
O Section 3700 of the Labor Code, for the performance of the work for which this
LO U
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier t Policy No. ry +� ,� * x srM
00 5 [1'4.81',t`.�ONW.r'�141 OI" 'P` =,E.1 r001119 0 1ywS����AL IA.TED CC OS Olin ��i�1.� RUIC-� OIN 10,ov o
O (This section need not be completed if the permit valuation is for$100.00 or less). PERMIT FEC SUMMARY
( ) I certify that in the performance of the work for which this permit is issued, PLAN CHECK FEE 101-000-43!1-311; �;ti,4aS
I shall not employ any person in any manner.so as•to-be"come^subject to the t'0�(V,J'ftti<=T1()NFIR 1()1-0()0-41R-(0 Stl?W y
workers' compensation laws of California, and1gree that if I should become N11-v"1 101-0()^-III.1•(2m 7.Gt3
3 subject to the workers'compensation provisions of Section 3700 of the Labor D.,EL--1'k�.CC`AL FE-1s-_POOL 101-W-420.000
Code, I.shall•forthwith comply with those,p4vlsions. �.
Date: Applicant �J —��-v 12f.lIM131NO F.HK--N0QL 1101-WO-419-0.) S''7.00
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to$100,000,in
addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to .the conditions and restrictions set forth on his
application.
1.Each person upon whose behalf this application is made&each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &shall, indemnify R(fB-WfMt.C0N8'f1 l-i( ('ft7N AND PT_AN(;Hf;t,W 1.0.9 0%
r�'n : +;
& hold harmless the City of La Quinta, its officers, agents and employees. LESS x+.+.z,1�`,,I)7 FEE 00.00
2.Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such )'('y�'t�),.$'F�ltitN ;.4+'L+; :.`i DUE,it OW $289.16
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 IIIIIIIIIIIIIIIIIIIIIIIII 07
correct. I agree to comply with all'City, and,State laws relating to the building
construction, and hereby uthorize representatives-bf this City to enter upon IE
the above-mentioned property for inspection purposes. - -
/�� RECEIPT DATE BY � DATE FINALED INSPECTOR
Signature,(O er/Agent) / !./ �w— Date
/A,,.- f. r �, —. r
i
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.Q. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS 1
Steel
Set Backs Electric Bond Cr/
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric U
Underground Plbg.Test
Final Gas Piping r
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 G1t:J
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
I
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
�x I
i
6
Final
Utility Notice(Perm)
_ I