0003-014 (POOL) y LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT PERMI; � tt1�
H ,Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION S10.04111.00 LOT TRACT '18,N7
Lu professionals Code,and my License is in full force and effect.
O =) M License# Lic.ClassExp.Date
I Q O,5j30,'211j JOB SITE ADDRESS 31-470 t11.7iel�HAR
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0 Z Date ._�' - Signature of Contractor « OWNER CONTRACTOR/DESIGNER/ENGINEER
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OWNER-BUILDER DECLARATION
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W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Ia. LA t„WV1'A CA 922 6 MIOENIX AZ 95034
U) License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (602)757-1656 CF�Lfk dAo(I
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 11t. it,AN"(At S1lik
contractors to construct the project (Sec. 7044, Business & Professionals
Code). VQ011.&61'A QN1.t-Nf,rlltlb> sf Srlttlit16lt5 SWALL,Wl IN PLACL.At PkE
M O I am exempt under Section , B&P.C.for this reason
N Date Signature of Owner
O0)
a Z WORKER'S COMPENSATION DECLARATION
oI hereby affirm under penalty of perjury one of the following declarations:
Lo H O O 1 have and will maintain a certificate of consent to self-insure for workers' r.)t11,r11Vi},GtZ SPA 10,0W.00 Lw
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q U y()< have and will maintain workers'compensation insurance,as required by
Q Q Section 3700 of the Labor Code, for the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No. �•, y ..�n N az x r ti`M� + r s i T t o
ao IIY>. i'OAIt'.51�1'UI' t .t',1.3�^Cif,�,.f.<_) aw ' 'a l ►a.Y1D COST OF CZ3�S1Z'1ZILCaani�
C1 (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, PLAN CHECK FEE 101-OUO-�439-318 $7rr US
I shall not employ any person in any manner so as to become subject to the �1T1`i'i ill tm*1 NJ FFI� I 0_(W-d1 9-000 yt 17 fK1
workers' compensation laws of Californ a, and agree that if I should become 01ECINA' .'CAL I`,UT3 -1'001. 101-000 Q I-0m, ;4I.00
subject to the workers'compensation provisions of Section 3700 of the Labor
TRItAL PFX--I'�)OL 101-000-120-00u �1'+.ov
Code, I shall forthwith comply withthose/_'
rovisions. 111.0 iIHIN.i 1-0i--IgXA. I01•(K)0-4t9-(MV $217.1,P
Dater -+'• r�-� 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 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 St IIA:f t n'A r,01Ni;`1'It I ICIT[f)N A•i`!TI PI-A N f`I IFCT $7RR 0%
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. L1:SS 1'1+1:-PAIy71'E :S $4 Qtt
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 •1•O`G%L YE.Ki1' IT 11'!I;!'S 0111+,NOW $2$+1,04
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
a correct. I agree to comply with all,City, and State laws relating to the building 03
construction, and hereby'iuthorize rrepresentatives of this City to enter upon IE
the above-mentioned property for inspec Ion purposes.
RECEIPT DATE BY
,
DAT INALE INSPECTOR
Signature (Owner/Agent) Date
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 7 GtJ
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric �G U
Underground Plbg.Test
Final 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 Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final 0
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)