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LICENSED CONTRACTOR DECLARATION
I h6reby 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 Ex.p. 10fe/
C53
Alate -,Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under. penalty of perjury thiti I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
� ) 1, as owner of the property, am exclusively' contracting with licensed
co , ntractors 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 -perfury 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.
(,A) 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:
CarTier Policy No.
STPUT-1 FUND 1610;
(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 subjd�t to the
workers' compensation laws of California, and agree that if,�!�Sh6u'ld become
SOO& to the workers' compensation provisions of Section, 3700- of the Labor
code, I shall forthwith comply With those prqyIS1ons,,.,,1_1
tdate: Applicant -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to cri m i nal. 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 B ' uilding 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 pers on 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.
Any permit issued as a result of this application becomes hull and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work'f(ir 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,r6laiing to the building
Construction, and hereby authorize representatives df this City to enter upon
the ab6ve- mentioned property for inspection.purposes.
/ignature (Owner/Agent),___�
Date.
PERMIT#
BUILDING PERMIT
4"01#457
DATE VALUATION WT TRACT
JOB SITE
ADDRESS CWT Mo
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
IMSE111T HIOU-SrENJOLLC
CAU'V010,11A POOLS &SPAS
5 PARK. PLAZA.K.M. 400
74-725 JONI IDJUVE,, fl.A
IRVINE CA 92614
PALM DENERT CA 012260
6W340-91MID C.Bloff 355
US E OF PERMIT
MCA, ANNOR '35PA
POOL Cht SPAON117- ALARAWMIMERS &W,(, W IN FLA.(Tt AT
PR&P]�A.'Tf WINSPI!,(7110N
P001. ANDAM VA PlY,1700.00 It's
L
"'OF Or.
INA 3 COST Or' C lv! TON
it Mj
.,S
r,0N'5,`1'R1JC'M)*J TrPT W4011 -419 -Wo $11180,w
POOL INIOM421-M
SACTRICAL:V03 -- POOL IWAY36-4.201000
PL`UWbfNQ, FEZ— P(Xq. 161-000-419-0W
U8-U'.PJ'X(, CCINSMIMM-NKNO PLAN CHT3CK
1.0" 0110
LESS PRE -PAID FEMS
$0 or"
1.XYr.AL.fT,HMff 14,0,1,S DUE, NO%V
RECEIPT
DATE
BY
DATE FINALED
JINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MEPHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Root Deck
ExhaustFans
OX 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
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings j
Main Drain
Bond BeaA,
Approval to Cover.
Equipment Location
Underground Electric
Underground PIbg. 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer -Connection
Encapsulation
Gas Piping
Gas Test
Appliances T.
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
j Utility Notice (Perm)
COMMENTS: