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LICENSED CONTRACTOR DECLARATION
I hereby affirm under nalty.,' Kperjury'that I am licensed under provisions of
Chapter 9 (commencin-g witiA� tion 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
3d£7ul� %53 i3 Y 1.406
Date 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'
compensation, 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 ,ass e�dyMMwrorkers' compensation insurance cayeietif ,,fpolicy 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 pr I ns of e I 3700 of the Labor
Code, I shall forthwith comply with tfigs isio4�-
Date: Applicant !i
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.
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, 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
yffor
riinspection
cuurposes.
Signature (Owner/Agent)%6if Date
BUILDINGPERMIT PERMIT# CONTROL#
3347
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 78.530.1 TC)TMF'.i3R SH
646411-048
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JUS't` Nr., A N.AG1.7LS
W>rS7ER111 POOLS
7853C aOrrrL.l•;wwt ti Uk
403375 h1ADIiSON ST
1.4 t 1J'INl'A. CA 9111M
IA DID CA, 92202
(619)347-5959 COLO 1.151
USE OF PERMIT
POOL AND SPA.
(1001, MI)IOR SPA i4,406.00 i:.S
J,,'STTrv1A1'ED )ST OCCON.V RUCTION
["Ift=H►3UT PRO, SU a7:N1ARV
PLAN CWCk FT.F 10,1-00043.9-318
f:-ONS'l ii:tlOTIak3 r� G li3!-C #111 -Ott WZOO
NrsC J14A341CAL VV65 -- POOL 101.00;-42140 $,24.43
:1.01 �(S00-4..20-W) .. .. 545.00
ref cr s rlrrC::rt .�. I�o�1: 101.006-t19-000 $27.00
SUB-TO"I't1:XXONS'rT1:C.JO`Tt(7N AND PLAN CHECK
$363.30
a— LESS P:1LE-.PAID FEES
nC).00
�D GLS
TOTAL P1~ RMIT 1GTES 011C NOW
MAY21.19f,9
R}r
RECEIPT
DATE
BY
DISE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
a'Root Deck
Combustion Air
Exhaust Fans
OX to Wrap
F.A.U.
naming
Compressor
I sulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali'Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS a SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final69
PLUMBING APPROVALS
S Test
d
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
Undergrourid Condult
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: