RPL (0002-215)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 Buisiness and
Professionals Code, and rriy License is i ' n full force'and effect.
License # I I ". . . .,; .. Lic. Class Exp.. Date
5741271�_ A
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 I the property, am ex ' clusively 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'
compensatioh, as provided for by Section 3700 of the Labor Code, for the
performance of tKe work for which this p6rmit 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
I certify that in.the performa,nCeZlf 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' dompensation provisGn§ oYSection 3700 of.the-LaIZ6r
-
Code, I sh - 11 forthwith comply with those provisions
�2 kf!�`Applicanf �41,
Date. t
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer tb*criminal 'penalties and Civil fines up to $100,000, in
addition to I the cost of compensation, damages as provided for inSection 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
& hold harmless the City' ' of'La Quihta',. 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 days from date of issuance of such
permit, or cessation of work for 180 days will I 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 auth oiize, rep resentatives of this City to enter upon
the above-mentioned property for inspection purpost2�
Signature (OwneRAgent) Dat61LZ/_7/,'Z21
Al
BUILDING PERMIT PERMIT#
DATE
02/171.21)t) VALUATION 414 0 Qftffl) LOT TRACT
JOB SITE -TPN
ADDRESS 79-040 WAIFUUM4
OWNER
CONTRACTOR/DESIGNER/ENGINEER
Aim''Wc-Z'r Unr lk"N`3 TNIC
42'..tJ %J A*
ON,
04, (0."11.
78-401 F fit GWWA Y 111
1.301.1 COU cRY;;I,(1E DR, Su.rffr.4,
LAQUKrA CA 92253
PALM DESER:,r CA., 92260 . k
(760-)1.16-4032 C_181A_11044',._
A1� Al v
USE OF PERMIT
POOL ANTNO-9. SPA
PLASTEIK INSPEC1 LON,
POOL kUMICOR SPA 40,000.00 L S
ES'"UNIATED CGS'17'01? coNsTRu.cTib.N
9411T FEE' SUMMARY
PLAN CHECK FEE 101 -WO -439-318 $227.18
co,wrl7tuurlow 5349-
., rl"�
rV.4
t4�? t t r jol� 101_000 00 Z
EUX CIMIC.1u, FEE �_POOL 101-000-4,26-000
Y1LWY.1BJN0'FGa' POOL, 101•-0(.K)419-000 $27.04)
FA 1, 0, 0 IN','; �11 UT C M-0 N A N'D P L AIN Ct4f ��C K
U -SS PRI-PAID.FrIES'
$0.00
3*0TAL PERMIT FRES DU ENOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
4
Tr
INSPECTION RECORD
OPERATION
DATE I
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
Insulation
_
Compressor
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Und roundprtri
U ground PI t
Final
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 "
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: