RPL (05-144)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
656,128 Cti � c 16f31f o
1
Date,<'dejlf 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:
( ) 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).
( ) 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•.&Wc ations:
( ) 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.y.l=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 9TATEs COMPKIMT1 Policy No. 0d00061d8-D1
(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 700 of the Labor
Code, I shall forthwith comply with those provisions f.
Date: - Applicant—
Warning:
pplicant 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 thes'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 appllcation•is made & each person at
whose request and for whose benefit Wprk 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 Cluinta, 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 80 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 author representatives of this City to enter upon
the above-mentioned property for I spection pur oses
. f
Signature (Owner/Agent) Date
4
29
PERMIT #;
BUILDING�PERMIT` h 5-144
DATE i VALUATION ^ . LOT TRACT
JOB SITE
ADDRESS
�y 'r —�—
APN v.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
f
ro ! U mE n
CALLWORRYA POOLS & ZWS CFECP MANCO
O BOX 1716
747125 J01,78 :'IR1 ITI, 81-1111-4A
LA. QUWA% CA 92-253
PAL 1: RIr CA 922,60
(760)3401-9000 MIX 00.
USE OF PERMIT
POD€JSPA„ . 3_XI'.M18/13,A RJF,?ZS 1,H& ..1. BE 114 Pi,B,,CE PRiO.ii. TO
,PR&PIA'S'1 R 1114M re3TIMI, S UR, 5' HJGH BLOCK WALIA
POOL,.AND/O:� SPA ul
s FT. WALL Q.00 U, ,
"[< 'LTD Con OF CO, NSMUCUMN
V,14.67 -f.20
PW.4 CHECK FU 101 x.0064439.318 v 28.-A)
r, 001' fiWCVGN FF.F, 101,400-419-000
00-419-000
MECHANICAL ME -- POOL 1.011.000 -4.i1, -O0.9, 00'
MECTMA71, ME - P006 7 ; ; $'"5.06.
POO.T, 1 011.000 19.000
6 2'02
ITYOFLAQUINTA
C CIT !
FINANCEDEPT.
tv��rf i� +afy �+��3�7t tic ypt1, w�h
sup, Iro 3rr�:.4 �4,dV!,7 A,JJ! tic I1()Y�I A:.LV.�.. .%��cF�!•F;l..
"lEM.I.I' 'd 5 DUE NOW
1902.70
RECEIPT
DATE
BY j
DATE FINAALEED/
`L9
MR
4
29
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
OX 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
2 _
Set Backs
Electric Bond
Footings —®
Main Drain
— _ L.
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
/6
Underground Plbg. Test
_ p
Fifaal
Gas Piping
_ p
PLUMBING APPROVALS
Gas Test
�, z
Electric Final
Wa ste Lines
Heater Final
Wat er Piping
Plumbing Final
Plur,,nbing Top Out
Equipment Enclosure
Shr,iwer Pans
O.K. for Finish Plaster
Sriwer Lateral
Pool Cover
S.;r Connection
Encapsulation
C3as Piping
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)