0006-389 (BLCK)_ LICENSED CONTRACTOR DECLARATION T'
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapte(9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. »-
License AA ��yyLiia Clas y Exp. bate
pp I1:
6 'f � C531 I 1 /3lie 2C
,Date Signature of Contractor
r
1 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). 4 !
( ) I am exempt under Section B&P.C. for this reason
Date 1 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
perfo�nance of the work for which this permit is issued.
_ ) . (.have and will maintain workers' compensation insurance, as required by
S�Ction 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 STATE FUND Policy No. 1344032-00
(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 s n is o'become subject to the
workers' comp nsation laws of CaliforniaraTid gree that if I should become
subjectfto tie orker ' compensat`o.- �rovlis"ons of Section 3700 of the Labor
Code, j�srlall f wi comply wlfh those�,pr)o �.
Date: VVVVVV pplicant ��`� W
Warning: Failure to se`cu're Workers' Com ensation coverage is unlawful and
shall subject an employer to criminal penalti.s 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
r.correct. I agree to comply with al City, and State laws relating to the building
construction, and hereby authori e�epresentatives of this City to enter upon
the above-mentioned property &,,i §pection purposes. t
Signature (Owner/Agent) Date
a
BUILDING PERMIT PERMIT#
DATE 06n012(X VALUATION $"m LOT TRACT
JOB SITE
ADDRESS w r-�it.���riL�a�i� �r'Y 1.. APN -
OWNER w S CONTRACTOR /DESIGNER / EN (NEER
M47I. Y POOLS CONUC"i'aON
49.580 MI ON D J�l X1+1 53.300 AV•! :t A MMU
LA Q'ULtiI'tA �� CA 92253 1A QLWTA CA .0, u253 .
S i (760)564-3655 CK4.2893
USE OF PERMIT t
4.
GMI7ZALB-0111DJOG l
StiPPi.LEMPNTAL TO PFRMIT 0006-M : 42 4F, i' H 0
(P60L E1QUJ1PMR4T PNC:WSUR ) C:I1Y'8TAABll.A.i D
3 FT, WALb 4100 LF
F
ESMA COFT OF Comptic'1:7Ion 9M.39
PERWi' rt n' 8'CTNI.ik(idllE Y
CONSTRUCTION IEL 101400-418-000 $23.00
SM40'I'AL CONSTiUTC TION AND PLAN CSC 14' $25.00
rEMS l�
LESS PRE: -PAA) .�.1x) r$0.00
.�.!L'rI�'�1!:�.'L'iki11aVD EO7Y r VYd�aT100
DATE I BY
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: