0404-025 (RPL)LICENSED CONTRACTOR DECLARATION PERMIT#
U) I hereby affirm under penalty of perjury that,l am licensed under provisions of - /t BUILDING
p+ PERMIT
'
� Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE <: r I VALUATION 91���JD.dYi� LOT 3S TRACT
W Professionals Code, and my License is in full force and effect. - .�
O n ch License # Lic. Class, Exp. Dater i toe SITE APN
.� v � fil,Ztl C 531 C C-8 tCt,3ld(t� ADDRESS _.._ :,�T_f�ITIFfd.-. - ..
O$o5
Y OWNER CONTRACTOR/DESIGNER/EN ENGINEER
Z Date �' 6ew✓ Signature of Contractor - �% _
Zo O_ o f 10�/'�J'�'% iR.'� SOM' CO1v�1iXN 13ll S,19C. C.t'Jf,.i1iCJ 4A.1POOLS & SPAS CMP MW CO3,
J U OWNER -BUILDER DECLARATION 200I? 'V1AZ%T1WGTl' X A� VIR if100 Bis -100 AM -TUR 54
W W I herebyaffirm under penalty of perjury that I am exempt from the Contractor's ' t "t
P tY P 1 rY _ PS`.J�ii"� �t�d20 Oi.AatsI LAA 5236
~ a License Law for the following reason: * .
00355
Z_ ( ) 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). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed 1pOt51.•A1MOft!,,V) A
contractors to construct the project (Sec. 7044, Business & Professionals rays •'sro 9 rix �%rr+, a 1 ..a�. �;� ry nxrn 'r Aa;e A •a
Code). L _ ..
() I am exempt under Section , B&P.C. for this reason ALJ. RMUDr3,RRIER.11 I LL 1-1 IN PI AC PRIOR TO PREPLAR 18}�
N Date Signature of Owner i3fSP.11ili'
O N ,.
Q WORKER'S COMPENSATION DECLARATION
CL
It Cr I hereby affirm under penalty of perjury one of the following declarations i��ltaLlalv}31JJ3:'h 14t41�0,00
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W L: compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q () ( ) I have and will. maintain workers' compensation insurance, as required by
O UQ Section 3700 of the Labor Code, for the performance of the work for which this
CL LO
Z permit is1issskueg., y�� r � cto�rnpensation insurance c re�i& p tcry no. are: �, �.� � .Pyr
oo = Carrier Policy No. PER15!`9.fi'MU FAT&D", RY
C) PIAN CHECK E 11. -000-439-318 S12830Q (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, C'OI�a'i UCTI0114 it' Y, 101-(3friJ-rl is -Gs.Q $198.00
I shall not employ any person in any manner so as to become subject to the MECHANICAL FEE- POOL 101.000.421.000 $29.00
workers' compensation laws of California, and agree that if I should become ZLFC:r1UWkL IMIL POOL. 101-000-420-000 $45:00
subject to the workers' compensation provisions of Section 3700 of the Labor PLIUMI' ING ME . pool, 101.000.419-000 $27,00
Code, I shall forthwith comply with those prolisions 7
Date: ��•� . • .' Applicant 6.,/ ZZ, tf Z26
f
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
Qraddition 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. o-
1. Each person upon whose behalf this application is made & each person at -r» RM- TAT' 0`0�UCT1011TAIM ��T��
whose request and for whose benefit work is performed under or pursuant to USS PAR -PAD s`W0
any permit issued as a result of this applicaton agrees to, & shall, indemnify D
& hold harmless the City of`La Quinta, its officers, agents and employees. 1"r13SDiirNOW
2.6Any permit issued as a result of this application becomes null and void if p
work is not commenced within 180 days from date of issuance of such k A('f� 0 6 Zflfl
permit, or cessation of work'for 180 days will subject permit to cancellation. U
I certify that I have read this application and state that the above information is CITY OF LA idlJiNSR,
correct. I agree to comply with all City, and State laws relating to the building FIlNAIVCE DEPT
construction, and hereby authorize- representatives of -this City to enter upon
the above-mentioned propert4"'t,
for inspection purposes. er j (
1/+' RECEIPT DATEF Jr BYE DA F ALED INSPEC O
Signature (Owner/Agent) E".'.r i Date £ � 7 � f d
r
t 1
INSPECTION RECORD
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Bond Beam
Main Drain
Approval to Cover
T
Equipment Location
r
Underground Electric
_
Underground Plbg. Test
Final
Gas Piping
_
- PLUMBING APPROVALS
Gas Test
Electric Final
V1 1 6
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
V
Gas Piping
Gas Test
Appliances
• Final
Z
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)
COMMENTS: