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,. LICENSED CONTRACTOR DECLARATION
,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
Zate14611 C53 3/3)/99
r"ISignature 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): 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.
CLMV2ITMN NA 101 011:1tW011440
(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 3700 of the Labor
Code I shall foqhwith comply with those provisions.
,Qate:7 ��� Applicant ; y-
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 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 representatives of this City to enter upon
the above-mentioned property for inspection' purposes.
vSZ
ignature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION S2�•11411< TRACT
LOT TRACT
,'4/19191+9 t),ilfl0,t1i1..
JOB SITE
APN
ADDRESS 79,231 CEfTUNO
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ti' ARVIN INN-T-SME`I FS WC
NIC1111r)'YRE POOLS a SPAS
i8.080 C;ALLE ES'TADO STT; 201
RO, BOX 1791
4,AQUIbr1'A CA 92253
LAgJ1NTA f'11 92251
(Trit)1'i6 _3585 z'4iT.t4 1945
USE OF PERMIT
Kx)L, ANDIOR SPA
110 1, MD SPA ONLY
P0()L ASIDfOR SPA Zt9.0c3fiM)o LS
USrIMATED CONT OF CONSTR UC710N
2C,43f14im)
PERMIT MIT FU StJtMMAM'
PLAN 011:(.'1. Fish 101-000-439-.418 S 13i.5�k
. )N-3TI IIt-710N 1PR1014N1f1AIR-f100 SV7(41
MIX-11ANIL"A1. FM -- POOL 101-000•4:1-000 10y M
1;fXA.'T deAf, FEE, -- POOL 1{)1-Ot30-420-ohi S45mo
1'4_UMBINt.E FEE; -- V001, 101 -0W -419 -GW
S1 frrTA1r coN,,zi'Its u7"ON ANN 114,AN (11i4k3
$417 S4
LuSti i'RE-T';111) P1:1::!
$0.00
TOTAL PERMIT C >H E S! DUK NOW
S437.55
RF,CEIP�t SATE
BY
DATE FINALED
INSPECTOR
F -
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.0.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior- Lath
Drywall -.Int. Lath
Final
Final
POOLS -SPAS I
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Wain 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.04t
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer LateralPool
Cover
----------- -
`SOWef Connection
Encapsulation
Pas Piping
'Gas Test
Appliances
Final
COMMENTS:
(i/�C�
Final
Utility Notice (Geis)
-ELECTRICAL APPROVALS
Temp.: Power Pole
Underground .Conduit
•Rough Wiring*
'Low Voltage Wiring'
Fixtures
Win -Service
..Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Use of Power
Final
Utility -Notice (Perm)