0003-012 (POOL) LICENSED CONTRACTOR DECLARATION /��J PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT INit) -U�x
fes— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION 1141.000.4111 LOT 4 TRACT 1874)7
CN W> Professionals Code,and my License is in full force and effect.
License# Lic.Class Exp.Date
r— ILJ Q 6.W%+15 I; 000120i JOB SITE ADDRESS 79456 A"I&R APN 769-4"-009
Z Date Signature of Contractor OWNER CONTRACTOR/DESIGNER/ENGINEER
m 0 1:.x`1'kol.-.44 ; f.;'. ItUT MVES`.1111 r."S,MC
� H o OWNER-BUILDER DECLARATION i
11.
U `�° I�.v I31)��aiu 1�iZ5 .uivIV1;R:�ITY DRIVE
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's ',,
a ILA QUiN"t'A CA H..s3 PHOENIX A.L 85034
License Law for the following reason:
Z ( ) 1, as owner of the property, or my employees with wages as their sole f�t}71�S7-i6Sb C,$T,# 6')9i)
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 Kxt l ANjj(]ik SPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 1, P001.,&SPA SHAt3,BE 1**6 i%i,rtCg t T PRE
c O I am exempt under Section , B&P.C.for this reason
N Date Signature of Owner
ON
CA
Q WORKER'S COMPENSATION DECLARATION
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o 2 Z I 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' 110011.r�tiii31O1'c',,)PA10,000,00LS
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) ( ) I have and will maintain workers'compensation insurance,as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
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L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
co Z5 Carrier 1N.".CO%IVAINY 017 T" Policy No. WDE1<<f i 19010 ENT1 oIATED CO"S"T OF CONS14,.:UT ON
a PERM]I]IT FEE SU14i!.MLARY
Q (This section need not be completed if the permit valuation is for$100.00 or less).
J ( ) I certify that in the performance of the work for which this permit is issued, P11 NN(HECK FE 101-000-439-3I8 S76.0
1 shall not employ any person in any manner so as to become subject to the fY1Tfa11T01("Pf0 NFFR, fill 4"-Al 94" $11T•(t0
workers' compensation laws of California, and agree that if I should become 1usClie;,'v'1f:r'�,I UZ_-FOOL 1 0.1-W.0 ;^1._CV114.100 ,
subject to the workers'compensation provisions of Section 3700 of the Labor ELEC;"iiUCAi.FEE—1'c 01, 101.-000-420-0W $45.00
Code, I shall forthwith comply with those provisions.
Date: Applicant 11Lt)1'Y11 tNU FEE--F'CK)L 101-000-419-000 q t7,ew1
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 CULT(7'f
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. $1"Ess 1.1;1.',-NAND Fr.111S w,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 •,1OTAJ,P1i;1114MIT FEES 0110 NOW $289.15
permit, or cessation of work for 180 days will subject permit to cancellation.
1 certify that I have read this application and state that the above information is IIIIIIIIIIIIIIIIIIIIIIIII 78
• 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 IE
the above-mentioned"prope rty for inspection purposes.
RECEIPT DATE � J DATF.F ALED 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 8 Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond - q/
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location ,�- {i(f JAO<,
Underground Electric
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 _ p
Gas Piping
Gas Test
Appliances
Final -O2
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)