RPL (9909-067)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I arn'licensed under provisions,of
Chapter 9 (commencing with Section 7000) of Division 3of the Business and
Professionals Code, and my License is in full force and effect.
License,# Lic. Class Exp. Date,12
;kIn". C33
tdate: .7L3&hignature of Contractor---,,",
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that l,am.exempt from the Contractor's
-License Law for the following reason:
( ) 1, as owner of the property,
ty,. 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 . . .. : . I I 1 1. .
I am exempt under Section B&P.G. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaratibns'
have And will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code,.f6r 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 Policy No:
. 'A, M, V., M", . , • ft*.- on ^AAe Iwo
til
.V 4,
(This section need not be completed if the permit valuation is for. $100.00 DO ' ess).
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 sub'ect_tVffle
worke/. compensation laws of California, and agree that if I'sh7ld"Erecome
suV.6ct to the workers' compensation provisions of Se6tip-31'040 of the Labor
Code, -I s al fo - .1with comply with those provis ions-.
Zate: Applicant—
Warning: Failure to secure Woreis' Compensation coverage is unlawful, and
shall subject an employer to criminal penalties and civil fines up to $1 00,000,'in
addition to the cost of compensation, damages as provided fdr 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 con.ditions'.andrestrictions 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 in ormation is
correct;.' I agree to comply with all City, and State laws re12oigTfo-the building
�r
con2truction, and hereby authorize representativeshl—s City to enter upon
th above-mentioned property for inspecti6n,. ss
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE (�qfe3llqf
'OVALUATION LOT TRACT
JOB SITE APN
ADDRESS 74-940 INUSSIONDRIVENVUSIf
OWNER CONTRACTOR DESIGNER ENGINEER
TD D 1:1 S I-, R T D E 'YC L 0 PYjZ N T CALIFOKKIA POOLS & SPAS
FO -BOX.- 1716 i. 74-725 JONI DRIVE, f1A.
1A (;�Uwrr.A. CA 92715. RALVII DESEW1 CA 9v2260
(7001340-9f.W)O I MR, 355
USE OF PERMIT
POOL '"i bic)k �_VA
Dr, 4 P lxa
POCOL Sr. FRI,, CitQY r ALAi8/Br
RXV1C41_14L9 814ML' �V L AT
,VH -.VI, 4233PEQ3'JQN
0044LANDIOR SPA I'S
^w c(X'%,!Sgo
11 A T "' COST
P4LA14 CHECK FRF, 1.15
COMSTR07, T(QN RE lf"1 t4t*_4184900 1.00
6
�&'CTJAMCAL F M PK)OL 10.1 _0010-421 I SZ4.00
PLM33IN0. MY,.— POOL
3 JP -TOTAL CONMIRLIC"JIGN ANID PLA'N CHECK
f M fS
1,J!SS E AID FU
7*01EALVEt n.j.,
A .
RECEIPT I DATE I By" '%_1,DATE FNALED I INSPECTOR
fe Af%0 A-4
A..."OVOW400
37A, 15
$0.00
INSPECTION RECORD
,OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Baclts
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 Hacks
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
ZZO
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: