RPL (0012-200)LICENSED CONTRACTOR DECLARATION .
I hereby affirm under penalty of perjurythat 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 Ezp. Date, ^M
Dates d ''E Signature of,Contractor P" _
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury•that I am exempt,from the Contractor's
License Law for the following -reason:
( )• I, 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),..
( ) I, 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:
O 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 fora which this
permit is .issued. My workers' ;compensation insurance carrier & policy no:. are:
Carrier Policy NO.-
STATE FUND
(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 those provisions. '
Date: i Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an.employer to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building andSafety.
for a permit subject to the conditions and . restrictions set fortii ,on his '
application.
1. Each person upon Whose behalf this application is made & each person at��,•
Whose request and for whose benefit work is performed under or pursuant•io }
any permit issued as a result of this applicaton agrees to, & shall,, indemnify, t
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued asa result of.this application becomes null.and void if
work is not.commenced within 180 days from, date of -issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and'state that. the above information is
correct. I*agree to comply with all City, and State laws *relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) a' Date "'N - 'F. v �
BUILDING PERMIT PERMIT#
DATT VALUATION LOT _•^r,Q TRACT
•_
JOB SITE
ADDRESS
APN
49 a 1 M.'QW&RA WA
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C"A 12+`'ai2%mkPoC3p & £kms
Psi -OX 371
4.725 JOVI ;?RJNI?; IlAA.
.GOA,. QL;+W T,A CA 92933
PALM DE,WR T 'Ch 92260 .
�e�6C113eL�i�'.•.� O C£� /k!' 5396
--
USE OF PERMIT '
POOL ANIVOR SPA
POOL &SP.A &:(2) WXTEX FXAYLIRE: e(1) SBQ
gFiAI.C..BE IN PLACE. AT .PRF
PLAS'J t R D43PEC:TION, POOL, N..QlllF'MENT MA' :iJ5l. RE 15 NUF PNIC1,131%f)
POOLATyDIOR SPA LJI
�'1�h?lf�.'�'.9±:I7•�`��.T ��` �'�3�8fir"�:1�IJ4:°�%�1t�
�v�;.
I'Y.MM!L'CE M4tU1 AKY
PLAN CLIECK FM . 101-000-439-318. S117,00 "
t;ONS`i`itil't". ION FEa34: i:sJ1 •�1 l�-Q'),$-000
WCHA'.N%CAL FEE -POOL, 101«000_121-000
.NUZTRIC'.AL, f 1:.*;• POOL 101-f A6, 0-til�Mibo $4N.(1f1
PLU,MBTKG T?Fg - ` POOLS `1 f11.,:Svk l 9-000'
9M, -TOTAL CC)A'fb;''i''R'Ugff0X AND P1,414 Ck ECK
$193,0L)
ZIRWPAU) PUS
$0.00
.�l v. rtiil.c ,�.,Lf IMJ i� y 5. .��.i160 1i.ei
Cif o
-�J
DEC 2 6;20,'g
r- -
UF I At
RECEIPT--
DATE'
6Y n!"
DATE FINALED
INSPECTOR
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
Bond Beam
Main Drain
Approval to Cover
_
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
Gas Piping
Encapsulation
Gas Test
Appliances
Final
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)