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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C,a,apter 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
1 W 1 /2-t
Date a� i „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&RC. 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.
(f ) 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.
(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 forthwith comply with those provisions.
Date: Applicant
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.
IMROR14NT 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, indemnity
& 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. ?�•
Signature (Owner/Agent) - Date F
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 00MO TRACT
1
JOB SITE Y
APN
ADDRESS
7eV-�wT 4.rR/1�o f.fsV1L4"f�
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OWNER
CONTRACTOR / DESIGNER / EN INEER
�.;` � .W41y CalOWEI..3a Ct2WAU911 M's
C ALTEY)�2IKA POOLS &.33PAIi
1535 s3, Tr mums s iwnOld
'34.4,25 JONS.p"lltME, NA
Mq B1�i.1�W.�I'.I'p4.'1 O CA, 92AO8
PKIIA �.T'a'.•l�iif"RT CA 92260
(760)340.9000 (MI 10 355
USE OF PERMIT
POOL AND/0)Z 'A
kf 011S.PAIE.SIQ (ANSI MALL HE
IN P;.AMAT PRE PLAVER JIMSTIR TION. POOL EQUIPMWT ENCLOff-URZ
IS N01' >HC1 UDTW 3N THIM PF-11MIT
POOL mw/Old sm 16,500.00 @,S
FS11T�►.. A IM COST fL Y t^; CA.ATI�x'.ERUMC3N
16,5W.01D
PIA 34 a111HE';I.1110; Btl'3�.f}tBO��!•��1d 3S $117100
Cf"tN."y=6'rPt.:3CTION FB 101-000-418-00 $ flt3.a4
MFIC WICALng__POOL 101.000.4421.000 FAIN
K'1.,IXI TI<IC,AL -0,. POOL, 101•-000-420-000 $45.00
P)JAMIN-1. ME Z =- POOL 301.000-4.19.000 �x1,00
H'
+`�.LTS-TOTAT Cows r 'f.7c'.1lSbA' maXl PLANCHEM
$393.00
IM3 T1R&.PXD 71MMS
$0.00
q
i ±moo Innour ras _TYU'I. ,KCWW
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OCT 102000
RECEIPT ��,
" 4
DATE I` "'('"'''"' `
, t (,If'o `
BY
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DATE FINALEDINSPECTOR
1
, INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K, to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
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)
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air I
Combustion Air,
Exhaust Fans j
F.A.U. I
Compressor I
Vents I
Grills
Fans & Controls
Condensate Lines
I
i
Final
POOLS -.SPAS
Steel
Electric Bond
ADDroval to Cover 1
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
.Pool Cover
COMMENTS:
FROM : CALIFORNIA POOLS AND SPAS
= _rGTED
PB
PB
PHONE NO. 7603465407 Oct. 04 2000 03:36PM P9
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