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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
"Cigapter 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
rS3 101-41
/Date ,r 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).
( ) 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 Policy No.
S'TAI'R FUND 444-984)0 04168
(This section need not be completed if the permit valuatiop)S for $100.00 or less).
() I certify that in the performance of the work for w idh this permit is issued,
10,
I shall not employ any person in any manner so a Ao become subject to the
workers' compensation laws of California, andgree trhlrsljould become
subject to the workers' compensation provlslggrrsof Section 3700 of the `Labor
Code, I shall forthwith comply with those p �s ' '
� s!
ate:
`1 ! rC Applicant—
Warning:
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 18Vdays from date of issuance of such
permit, or cessation of work for 186ays wjll.subject permit to cancellation.
I certify that I have read this applicatic
correct. I agree to comply with all! pit
construction, and hereby authorize�ri
tthe4bove-mentioned property foFlihsr
Signature (Owner/Agent)
'state that the above information is
State laws relating to the building
itatives of this City to enter upon
purposes.
Date
BUILDINGPERMIT PERMIT# CONTROL#
DATE l I VALUATION LOT 9803-219 TRACT 8712
315.41100.00
JOB SITE F J
APN
ADDRESS
79-214i' cY'rxtlwO
OWNER CONTRACTOR / DESIGNER / ENGINEER
MARVIN-HOMES CAL11-0KNIA PUULS & SPAS
M-310 AVENIGA BERMUDAS '4--025 , ONO DRI1 E, #A
LA QT NTA CA 9225: PALM DESERT CA 92260
(71:+0)'2110.9(0 CBL# W +
USE OF PERMIT
1iF111.1)11Ns sPAM
tf..)t=)L A.T D'St�A /BBQ)
APR U 11998
CITY OF
LA QUINTA
POOL ANT)iOR SPA 1 S.1)I JOP LS
s 1
h:.NTEMAT943) CON10 CONS 1'1tUM 10'!'
15,I)1l1i. o
PERMIT FEE, SUNINtALRY
PLAN CtW.0 ; FEE 101-000-4139-31 R 11105.:30
c;ONSTRIKI'WN FLE 101 -000418 -ow S162AK)
NtHCHANICAL FEB -- P001, 10140(1-411-0011 $21.04
Fiuw rRIcAL F'FF3 -- vc)oi. 1101-000+11120.000 x14.00
PF.IJKTRING FFX -- PCKiI. 101-000-1119-000 S27.00
SUB TWAL CONSTRUMION ANIS ELAN CHUCK
$30 10
1,FSS PRls-PAII) IFI:1:S
tu.(*
TOTAL PERMfT FEES DUE NOW
5363.30
it ;�
RECEIPT
DATE
BY
DATE FINALED
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
Steel
POOLS - SPAS
—
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
(p v t✓
Underground Plbg. Test—
'L �' 4(/
Final
Gas Piping
—eel A4e-r
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
��ewer 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
c
I
Final
Utility Notice (Perm)
COMMENTS: