9610-045 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License #. LickClass Ex D to
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Date 16-11 * � Signature of Contractor .t J U, I., `144 -
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 fog workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
P4)--I.have and will maintain workers' compensation insurance, as required by
Section 3799kofEtheL-J r Code; for the performance of thel.work�, for which this
permit is issued. My workers' compensation insurance carrier & ,policy 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 provisions'of Section 3700 of the. Labor
Code, I shall forthwith comply with those provisions.
Date: AoDlicant
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 3708
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 aCity and State laws -relating to the building
construction, and hereby authori .e representatives of this City to enter upon
the above-mentioned property fo Inspection purposes.
Signature (Owner/Agent) ;F t- Date i)°.Ue
BUILDING PERMIT PERMIT#°NTR°`#
!!61 4f -{i45
DATE VALUATION �''i�+'� LOT TRACT. 4 211
JOB SITE 45,070 B . if)(JII ; UTE WAV
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C;4 A1) t\N1) ROS. 2, AN E PAYNC
SUNIUSIE POOLS .
1...A QUINTk CA 92253
PALM. 0,13,81IM' CA 42260
t+I�?_�fz()-�2e?/!
1f19>340-5521 CRI -Jif 1504
USE OF PERMIT
I :X)L AN},trC, R SPA
KIC.'i3. ins SPA. ONLY
as;^ �:•r: cry,. � .,
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1'i±;.�3.iVli`.0 tr'6+.;it; St.l��{d4A:[IdY
PI; AN 1"71 XV... FTMIi.flt-tbiKi ,43�-3€IG $i`J 1.15 .
flit'€'il?.Lr!:;`i'tt:�I�76-'ks'1� ��i.-Q00•d3.F�• �lip.JO
W1.0-1ANIC.Ad rIT-3--POOL 014- 00421-910
.8C1R1'CAL F86 -- POOL 101. -010 -X120 -WO 545.60
'LCL QW111`40 FBF Pool,. 101-000-419-000 5u7.12(i
..°CCyrl co ZUC"'('!•ON AND Pt..}1NI C14ECK
$3.7$3. 115
•. LESS PRP -PAID FEES
so.00
1g6
TUrAJ, P�',RN41* FF ,s DUE NraW$378.15
RECEIPT
DATE
BY
DATE FI ALED •1N5PE T
a5a�v
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
Fire lace 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 Pibg. Test 4a4 44W
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Tdp Out
Equipment Enclosure
Shower Paris
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)