9904-165 (RPL)` LICENSED CONTRACTOR DECLARATION
I, hereby affirm under penalty of perjury that I am licensed under provisions of
_4Z
'~ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
y r141�W Professionals Code, and my License is in full force and effect.
' C:), =) CV) ' License # Lic. Class. Exp. Date
w� ti5ci12B C53 (31/00
.r—
t�
o Z Date Signature of Contractor
:V C) OWNER -BUILDER DECVA'RATI
HW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
t>1 License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole
x 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.
0:16- 1*14. X 61600
(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 becomvubject to the
workers' compensation laws of California, and agree that iff1 should become
subject to the workers' compensation provisions of Secti ri3700 of the Labor
Code, I shall forthwith comply with those provisions.
ate:_7 Applicant
Warning: Failure to secure Worker"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 permit subject to the conditions and restrictions set forth on his
application. f
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 S9te laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the bove-mentioned property for inspect'6" purposes. ;
Signature (Owner/Agent) Date
i t/A
BUILDING PERMIT PERMIT#
DATE 4119M VALUATION 3111,600 00 LOT TRACT
JOB ADDRESS '9-2741;:ETRINO
APN - -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TD. DESERT 1JE'L'TsLOPNi1:N'1'
CA'i IPORNIA POOLS &SPAS
P.O. BOA 1716
74-7225 JONI DRIVE, #A
1.A f UINTCA CA 92'251
PALM DESERT CA 922(k
r7c t�a3T[�-!fib 01114 355
USE OF PERMIT }
POOL f1N[ 0R,,SPA
P 0oU,SP.k1 WQ - ALARtti1 HAR1iTMiftS MUST BE R-1 PLAM AX
t'1tT=, PLAS`t`H.R .4NSI?R01101K.
ALLJT1A,1)Cei"1 10,6100.00 LS
PERMIT FEE S(.fMMU1I` V
PLAN C11Cat;.K 1• FI?, 101-000-439-31.8 $12830
e,�ONAT.RYIf TIONF1T 101-W-411,M)O $19801
NZA-1TANiCAL FEE --41001. 101 -OW -4.21-000 $24.00
RL'ECIlUCAL Fa, —Ptx L 101-M-4261.000 S45.uo
K.U1V1B.iWO Vt% --- 1 JOL 101-000-419-000 $27,00
ST)B-TMALffft' T'RTJCTION ANIS PT,AN f.31KM
$42170
ESS PRE -PATI-) RTS
$0,00
TOTAL !'1F:4tN'i T f'KI!N DUE NOW
$422.70
RECEIPT
DATE `"
BY j�
DATE FINALED
INSPECTOR
•J /i
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
L.Z
Set Backs
Electric Bond
G • 2
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
2
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
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:
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