0005-091 (RPL)LICENSED CONTRACTOR DECLARATION
I herebv affirm under penalty of perjury that I am licensed under provisions of
G40,9 (commencing with Section 7000) of Division 3 of the Business and
Prials Code, and my License is in full force and effect.
Lic. Class Exp. Date
1 656128 C53 10/31/2(
,Date Ai( 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&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'
cortipeitsation, 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 STATE FUND Policy No. 046-00.0000163-00
(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 Ion 3700 of the Labor
Code, I shell forthwith comply with those provisions
Date:! Applicant A
Warning: Failure to secure Workers' CP p'ensation 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 persori 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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection�urposes.
Signature (Owner/Agent) �Date/_
- � BUILDING PERMIT PERMITT###
005-091.
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 79.4jv.LTGA
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TDD 1 iRt RLOMIENT
CALWORNIA POOLS & SPA! S
79-4101aGA_
74.7x5 JON :I' IVU,# -A
;LA QUINTA CA 92253
'PALM D'ANS°rOF;T CA 92260
(760)340.9000 GB' 355
USE OF PERMIT
POOL AND/OR SPA
POOL. & SPA 014LY - ALARMMARR.IERS SHALL St IN P1..A.C:E ,AT
P PLASTER INSPECTI(M.
POOL ,P—MORSPA 1B
ZS111M M. color OF CO0SIMI7170N
PERMT M SMUKAMY
Pili C1 40K FEE 101.000439-318 $105,10
CONSTRUCTION ITS 101-000-418-000 $16100
I+CAE4 NA1+11CAL FEE --'POOL 101.000-421.000 324.00
XLECTRICALJF X >- POOL 10.1 -MO -420.000 W.00
1'iJl.1A RING FEE -- POOL 101.000-419-000 S".00
s
-7 01AL CCi1 MUC-11014 AND PLAAa' CXWK
V.4t6:3.:3Q`
iY.S9 PRE-PAMF
$0,00
TOTAL 1'MAURTMS DVE 14CJ's
1"(13IM
r;
RECEIPT
DATE Bl' .1
DATE FINALED
INSPECTOR
106
. 41
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
MECHANICAL APPROVALS
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
POOLS-- SPAS
'
BLOCKWALL APPROVALS
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 -
COMMENTS:
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)