RPL (0004-265)'. LIQ eNSE6 CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions o
Chapter 9 (commencing with Section 7000) of Division 3 of the Business an(
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6129 053 ,. 10{31i21C
600 " X
Date C Signature of Contractor
I -';
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor':
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 foi
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensec
contractors to construct the project (Sec. 7044, Business & Professional;
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 STATE FUND Policy No. 046.00-0006169-00
(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 so as to become subject to the
workers' compensation- laws of California, and agree that if I should become
subject to�the wdrkers' compensation provisions of Section 3700 of the Labol
C.o'de, I�shall 1 4W'th comply with those provisio. K
date:{��%`c-Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful anc
shall subject an employer to criminal penalties and civil fines up to $100,000, it
addition to the cost of compensation, damages as provided for in Section 370E
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 al
whose request and for whose benefit work is performed under or pursuant tc
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 ii
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 .represe�r tatives of this City to enter upon
Zture
b'oove-mentioned property for
spectio �urposes.
(Owner/Agent) ✓'✓� Date
BUILDING PERMIT PERMIT#
0�-26th
DATE �j, VALUATION Si5i0w= LOT .32 TRACT ZIR912
JOB SITE �YIT'J'J APN
ADDRESS 49-920 hMSION DRW- F WERr 64"10-005
IOWNER
T.1). L9E&KC DENW OPMMU
P.O. BOX. 1736
LA QUINTR. CA. 92253
USE OF PERMIT
.b'OOL ANINOR SPA.
CONTRACTOR/DESIGNER/
CALW01UI"iA POOLS & SAB
74.725 JONI1D ..4 AA
PALM DESERT CA 92260
(760)340-3000 CEIR 355
pP�OOL & SP.r3<t3NI,Y- .ALA RRIS'II3AI`''RIERS SHALL BE ltd PLACE AT
1-I'wl+: PLA.ZTER INSPECTION
J
VALUATION
14000.00 W
E!>"T31VU1`FID Coss OF CON&"FRUC1110N
PERWr FEE SUA I"RY
PLAN CHECK flu
101.000.439.318
$105,30
COIVSTRUCTIO14 FEE
101-000-41$-000
$163.00
MECHANICAL IEEE
101.000.421.000
$24.00
RI.Et'TRICAL PEP, -- POOL
101-000-420-000
$45.00".
PLUMBING RE -• POOL
101-000.419-000
$27.00;,.
c
SUB -TOTAL CC9k]S UMON' AND PLAN CMCT:
LM PRE -PAW FM
/'R.r cRECEIPT DATE
TOUL PL+RWr MS DUEE NOW
FINALED
's"= UO
3.51000.00
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
Steel—
POOLS - SPAS
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: