RPL (0002-402)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 Exp. Date
4954!)F+ 13 x;:31 U1,31i2ot
'Date ^�a, ' Signature of Contractor,'Lf
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:
( ) 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.�l�a��♦cuvl Policy No.
11
t.xi.�i >:s rrta. tib -v
:�.i593
(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,tho'se provisions.
Date: - L 7,-. r Applicant ,9
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
& 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 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) of fr-y %" adJ:'Z.t � Date
BUILDING PERMIT_
VALUATION LOT
JOB SITE ADDRESS 4.7-9501�U��A i OVI[Ki
OWNER
A T�R 'h2r1e,'111T na r P•�rMI'C'C'f'P
LA.Qf3lNTA CA 42253
USE OF PERMIT
PERMIT #
0001-411112
TRACT -,i
APN
CONTRACTOR / DESIGNER / ENGINEER
P.O. Box. 1 524
PALM DESE11cr (',.A 92201
t~ii; a 775
til. OL & SPA ONLY- ikLA ui6risiOW IRKS :;fits;, .6E iii PLACE Ili PR.L
FOOL AMWOR. 3PA
i 11,400.00 I'S
.ii,l. I&r3ty�up s�..Mai .e EjY' `.'t�.ibr:3�i dgs.l �,�t t�, on?e
t a��kw.e,
PERMIT VESfiUNI—MAR
PLAN CH)-.ieK FFL
101-000-134-318
7 is
( 014f;'f'R1TVT:J0N frPR
101_00(1_44841"
7 i5 f1f)
IM17CHANIC L--1'OOL
10.11-10100-4411000
524.010
k LI�Cr(ft1CAi.. PEL- -- 1Sc:Ii: L
10 i 4*0420-000 420-000
$i 4.Uo
K?AIV11114IJ FFE __ POOL
1014)00-419-000
1
Si f1i-T0 1,f+,i.(''oNsTRt i("TT(N �4,!v) Pt A,N rf.fti r%, $i(9 7"
to, 00
RECEIPT I DATE
TOTAL, fN,1 LNCYF :H' FF;51.DTJ1:.NOW
DATE FINALED I INSPECTOR
$318.75
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs !
Underground Ducts
Forms & Footings I
Ducts
Slab Grade (
Return Air
Steel [
Combustion Air
Roof Deck i
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing (
Compressor
Insulation 1
Vents
Fireplace P.L. I
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall t
Exterior Lath I
Drywall - Int. Lath i
1
l
1
Final
Final I
BLOCKWALL APPROVALS
steel
POOLS - SPAS
`
Set Backs (
Electric Bond
Footings l
Main Drain
(%
Bond Beam I
Approval to Cover
I
Equipment Location
I
Underground Electric
I
Underground Plbg. Test
Final I
PLUMBING APPROVALS
y
Gas Piping
Gas Test
Electric Final
-?e r
Waste Lines I
Neater Final
Water Piping I
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans 1
O.K. for Finish Plaster
Sewer Lateral f
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping f
Gas Test I
Appliances I
[
Final
t
t
i
Final {
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring I
Low Voltage Wiring t
Fixtures I
Main Service !
Sub Panels I
Exterior Receptacles
G.F.I.
Smoke Detectors I
Temp. Use of Power
t
t
Final I
Utility Notice (Perm),
COMMENTS:
FROM.: PURRFECT POOLS&CONSTRUCTION FAX•N0: 7603609829 . 5 `Feb_ 22 2000 08.52AM,tiP3,-y,
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