0003-011 (POOL) ~ LICENSED CONTRACTOR DECLARATION
aBUILDING PERMIT PERMIT#
U)
I hereby affirm under penalty of perjury that I am licensed under provisions of r� i'� f�1�;�-t►11
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DA E VALUATION S1%t)00.00 LOT TRACT 218797
N w -Professionals Code,and my License is in full force and effect. . . ---
License# Lic.Class• Exp.Date
o O r�CxidS $''' €wf i2(il JOB ADDRESS i9-460AYA11AR APN 70-460-008
t` r- C7 / OWNER CONTRACTOR/DESIGNER/ENGINEER
o Z r-- Date �e �Signature of_Contracts
r— Ho OWNER-BUILDER DECLARATION
_JU .G BO 3iG ldl�R.L3 iiv.iifcSi 1'�'uRi'v'r,
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a I.A QUINTA CA 922-53 PHOENIX AZ 85034
License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole (W-2)2574656 f ;(� �i�34O
compensation,will do the work, and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed POOL Al'NLUOR SPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). POOL X_SPA UN-i,ti-iILARMSl6Aiu'tiERS SHALL!iE IN PLACE AT t'.iRE
c () I am exempt under Section , B&P.C.for this reason YLt!iy`lr1k 1N8k'1%C Yi()h
N Date Signature of Owner
O CV
C7
IL Z WORKER'S COMPENSATION DECLARATION
le C I hereby affirm under penalty of perjury one of the following declarations:
y�
Lo H O ( ) I have and will maintain a certificate of consent to self-insure for workers' POOL�t\T'�W OR S--A W1,00.00 LS
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q L) ( ) I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No. , r n t rin r+ l t t
ob 5 INS.C'+ONITsANY OF T .100,1. flt+-1 1900 ������Z�3.,sib 11-10ST OF COINS1'$.@1O'nCIAd 101900.00
PFIR&UT FE 1.SUMAIARY
(Thi�;section need not be completed if the permit valuation is for$100.00 or less).
A )-certify that in the performance of the work for which this permit is issued, I'I`I t U3~LI` I �k' 101-0M439-318 $76.05(shall not employ any person in any manner-sous to become subject to the C'.lOWSTRI[C"rRYN rj;71, f01-M. 11�41I9-W gr 17.on
workers' compensation laws of California,and agree that.if^I'`should become i ;C,Ti,<<::«1.eIL` --` �t=1;. ;�?3.- U."rte;-(1v� AM n,
subject to the workers'compensation provisions of Section 3700 of the Labor
� ii.�i;'I'x<1C'Ar,Ft�l:—�:►uL I.G,L-CtUU--)2l�-ut1U ��.U1J
Code,I shall forthwith comply with those-
provisions.
Date: 1` "A�plicant i'LLIM1#1NO 1 FE--11CK)L t 01.000.119-000 $27,u11
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 applicaton agrees to, &shall, indemnify �t-ri _rel4:A���C�N:�Thf_1(:T1r� (Al�I1i T I,AN yt9�{ 29-05
& hold harmless the City of La Quinta, its officers, agents and employees. ).1: S PR E-VAID TALE': $0.00
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 1.01-AL13iiRNif"ll VEEN OItfN1v0W 5289.€15
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 IIIIIIIIIIIIIII�IIIIIIIII
• correct. I agree to comply with all City, and•State laws relating to the building 01
construction, and hereby authorize'(6presentativesFof this City to enter upon IE
the above-mentioned property for inspection purposes. ---
�� , RECEIPT DATE BY + 12 D T IN LE INSPECTOR
Signature (Owner/Agent) F �--- ------ Date �'^ �• a
14 ~
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 w
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location —'G,1!
Underground Electric
Underground Plbg.Test i
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 477 �-1
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. l
Smoke Detectors
Temp.Use of Power
I
Final
Utility Notice(Perm)