9610-035 (RPL)LICENSED CONTRACTOR DECLARATION
��j_l here4y'affirm under penalty of perjury that I am licensed under provisions of
'TC-hapter 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
0 1 �14� 1. 1
Xate 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:
( ) 1, as owner of the property, oi� 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
contractors to construct the project (Sec. 7044, Business & Professionals
Code),
0 1 am exempt under Section -, B&P.C. fot'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.
()J I have and will maintain. workers' compensation. insurance, as required by
Section 37 the.
ROA91.1-Ay or Code, for'the performance of e,�t�k,.for which this
i " IN T I �11"
bermit i workers' compensation insurance c ir ljporicy no. are:
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 agreethat if I should become
subject- to the workers' compensation provisi?�sjqf Section, 00 of the Labor
/D ode, I ShAll fprthwith comply with tho oZvifjns
a lit A plicant
te. A 'T_ p
WarniWrFailure 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, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issuedzs a result of1his 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
ct. 94 -7
the,above-mentioned property for inspe io urP0 ,
!pe
nature (Owner/Agent)
.8 /ig If 0
PERMIT 46 A p-4) j.,� CONTROL# V
BUILDINC
DATE VALUATION LOT. TRACT 4202
_I C)
iOB SITE Z�.V FM 4_111kK IKV Alill,1118
APN
ADDRESS
OWNER
CONTRACTOR1 DESIGNER ENGINEER
N't I, N I 1111RE I I 1 .1
MCWTYRU.' POOLS &-!WAS
443 W11-f�11,1U)OWS
.16-Jol ROUDEL LA14R'
LA
(,A QUIN'17% CA 022511
56.111-1941
(6 1 9)_14 -.l I 03L0 10i 15
USE OF PERMIT
ik 4 A - A N 014 W. SPA
P00L ANJJSI.`�A.
04111MATUD CONTOV C0NS TRUCTION
V E, HM IT F F. V, S I J! M A R N'
PLAN CHECK FEE 4.39 -SIX
1STR1JC`T((.)N FhR W! _0(yli 1 1118-1-101)
1�011ANJICAL l4i'l', K)(A. 10 1 -W-42 1-000
F-'11FY.1RJCAI. FOY P(A-A, 101401-11,A) 00)
131.1 WIT.11NO FV1" , "(71L 101-000-1194X)O SIVJ)o
SU1,11VI'AL CONFTRUMON.W.D PLAI�l CHECK
S30 30
$0.w
TOTAI, VIVIRA-11'r FEEN DUE, N13W
RECEIPT---
DATE
DATE YINAL
INSP
JBY
31 2-17
7T
-4
INSPECTION RECORD
OPERATION
I DATE I
INSPECTOR
OPERATION
I DATE -TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs.
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum 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
Dr/wall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric A A
Underground Plbg, Test A'),
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPAns
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation 91
Gas Piping
Gas Test
Appliances
Final J� Lt Ldq' 1
Final
U014 Notice (Gas)
ELECTRICAL APPROVALS
Temp., Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility N;t�(Perm)
COMMENTS:
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