RPL (0101-329)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class /11 Exp. DateJ+y ?NT
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
sale (Sec. 7044, Business & Professionals Code). •
( ) 1, 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 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.
'Me AT E IW D tfal�^ a� til l7�
(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,
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'hose proviso. • ns. .
Date: A.'� 1 Applicantb� 1%j �b�%
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 `t
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.
& 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 jdays 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 is
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
the above-mentioned prorerty foonspection„Purposes. t
1 �
Signature (Owner/Agent)bi y B �� Date 4 �3
BUILDING PERMIT PERMIT#
DATE VALUATION LOT,TRACT
JOB SITE
APN
ADDRESS
f i AWNUHA. W A Ll
OWNER
CONTRACTOR/DESIGNER/ENGINEER
:r.`,1:ls.:I.)1+'�'`NMT DFV34T',,OPI%f;e3't'
CAI.1irOMA POOLS & '.A0
C), BOX 1716
7 4 -7 25 J014'1 DFAVE, AA
LA. (JUMA CA 92253
I)ALMD]WRI CA 92260
(760)340.9000 fapnk• 5386
USE OF PERMIT
P%'OL!arNVM?. f'A
POOL c3:..SP.A. MS..rt'eALARM.a&l:RI.ItiER'Si�SHALL HE IN PLAC Y -AT FRIE
PLAZ1':M IMPFCT.M.POM EQUIPMENT ENC1,03[Y-F INOT IIVC[.►YIleD
COW OF C4?MMUMION
PERMUM,
Pd.•f N CHECK ME 101 • 00(.I•39••316 $129-ffi
OONSTR.UCTTC3.X ME 101 -000418 -OC 1;) $199.00
14201RAVIICA, F42 -- POOL 101.000.421.000 $240
FILECI!'PUOeP3L blit POOL 101-000-4.20-000 $455.00
1'1,.13MIMO 71101. -- POOL 10 1 -000-419-000 MAID)
i
k
SUB -TOTAL CONSTkt.'(JM0,39' D PY_AW C11MK
P122.70
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a TWIPAt PENKC11 F nXIS DIX ROW
JAN 3
NIT Y ,Vi=i
RECEIPT
DATE ; / /
BY v
DATE FINALED
INSPECTOR
v' '
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
Set Backs
Electric Bond
Footings
Main Drain
n
Bond Beam
Approval to Cover
j
Equipment Location
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
?� _
Gas Piping
All
Gas Test
Appliances
Final
COMMENTS:
`66
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)