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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
C11j)ter 9 (commencing with Section 7000) of Division 3 of the Business al
.Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
�93i.01 A C10 ar�l/9�e
date Signature of Contractor i-'-"
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contracto
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sc
compensation,,.will do the work, and the structure is not intended or offered f
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with license
contractors to construct the project (Sec. 7044, Business & Profession'
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 declaration
() I have and will maintain a certificate of consent to self -insure for worker
compensation, as provided for by Section 3700 of the Labor Code, for tl
performance of the work for which this permit is issued.
(4 1 have'and will maintain workers' compensation insurance, as required I
Section 3700 of the Labor Code, for the performance of the work for which tf
permit is issued. My workers' compensation insurance carrier & policy no. al
Carrier Policy No.
STMT :��ND
4f 9 t
(This section need not be completed if the permit valuation is for $100.00 or les:
( ) I certify that in the performance of the work for which this permit is issue
I shall not employ any person in any manner so as to become subject to tl
workers compensation laws of California, and agree that if I should becon
subject to the workers' compensation provisions of Section 3700 of the Lab
C16de, I shall forthwith comply with 1hose,provisions .
Y ate: f. '" - P' Applicant 6
Warning: Failure to secure Workers' Compensation coverage is unlawful al
shall subject an employer to criminal penalties and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in Section 371
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe:
for a permit subject to the conditions and restrictions set forth,on h
application.
1. Each person upon whose behalf this application is made & each person
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemn
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of sw
permit, or cessation of work for 180 days will subject permit to cancellatic
I certify that I have' read this application and state that the above information
correct. mag ere to comply with all City, and State laws relating to the buildil
const�yCtion, and hereby authorize representatives of this City to enter up
the above-mentioned property,for inspection purposes.
(Signature (Owner/Agent) Date"
of
BUILDING PERMIT PERMIT#
41a�ilti_1./9i
id DATE VALUATION LOT TRACT
JOB SITE c JAPN
ADDRESS 79-075 ASH.LEN P.i Ait:E ,
OWNERCONTRACTOR/.DESIGNER/ENGINEER
011111.001 ''11111I(R13(d�.!SKI R rrrAU jNjGI1iUXIMON
.s 79-015 ASHLEYPLACE 63-W> BABADA
( E1 QUI14"rA CA. 9225:3 C;AT'E(130RAL CITY CA 92234
le f7(50?IFSt-:ifi7i 031A, *50
or
USE OF PERMIT
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Is POOL ANEXOR SPA
POGII..i W,A, MLAA;tM3fDAKRY.CcS SHALL 13C IN PLACE AT .PId.&PLASTM,
S:
's rt=uv1. Aiv/.s:012 SPA (� t.ITu.Gu T..:,
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ESTIMATED COINIT OF "CIGININURIVI'MON A13. W0.00
d, PLAN CM -CK FEE 101-000-439-318
1e a"Cs?,F4"f�d"1'f�^(`4r1i3'twS,t f(3f4}(1!'1. tIR-f)w '"�tlit!!ifl
1e 1 '� C.d1 LAICAL ,FIX --POOL x01 i1G4 ��1-OtSD ��1.!iCt
or i :4..J~V"#"lMAL FE.Et -- P(., EOI A10.420.00 3 $115.00
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h 1113'x,`L P:!?.l�i'vi#1' FEES b9UE+rNOW $333.60
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RECEIPET� ` /� DATE BY D E IN L INSPECTOR
�� '141 iMt v O/1'
INSPECTION RECORD
A 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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - 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
Underground Plbg. 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
O.K. for Finish Plaster
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
UU14 Notice (Perm)
COMMENTS: