0006-377 (RPL)SED CONTRACTOR DECLARATION j .-rr PERMIT#
U) I hereby aff enalty of perjury that I am licensed under provisions of l✓ ''`'j BUILDING PERMIT
F-
Chapter 9 ommencm with Section 7000 of Division 3 of the Business and ' 17
p ( g ) DATE VALUATION LOT TRACT
N W Professionals Code, and my License is in full force and effect. S2r4,I100.�1C1
O M License # ' Lic. Class Exp. Date
LC)LLJ 777601 �`�'' �C.S3 �, .- rtQ O/��.,.... ADDRESS $:s-26013IRM4311;'1JOB SITE� 7 WAY
APN _
t` It-
Z VD6�el<_ 'f�Signature of Contractor /F� %���` - ; OWNER CONTRACTOR / DESIGNER / ENGINEER
coo O O OWNER-BUILDER DECLARATION / I IC&C.ATiI.t:. UZON� CAS...-XE'V'_T1OC.'LS,1NC.
� 0 `r,° 45.260:t3�liXiEr BWAY '70.1$0'IT *0_VFi£�i ROAD 63
W W I hereby affirm under penalty of-.perjury that I am exempt from the Contractor's y
I— a LAQUI1�!-LA CA 92233 RA3dCHOMUZAGE CA 92270
U) License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)$31'0$60 CI1W, 3735
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 POOL ANDIOR IPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). PC)CIL& SPA ONL.YW,a3ftMSIHAitft1Et25 SHALL HE IN PI.AG.r. AT Pi l!:
CY)() I am exempt under Section B&P.C. for this reason PLASTER iNSPNsCTION.POOL EQUIP I314CLOSUR.9181` NOT r14CLUDLr;D IN
N Date Signature of Owner THIS PERNUT
ON
O
d Q WORKER'S COMPENSATION DECLARATION
'O Q IM I hereby affirm under penalty of perjury one of the following declarations:
r POOL AND/OR SPA 24,000,OG IAS
1-.;O () 1 have and will maintain a certificate of consent to self-insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance.of the work for which this permit is issued.
Cal Q 1-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
tl 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier KNEWI TION ON KILL Policy No. XSA7l TA7.XD VXW OF CO YMIT M70111 24,000.00
J (This section need not be completed if the permit valuation is for $100.00 or less). PLAN CHECK FRE 101X000439316 �! $Isf�
`
( ) I certify that in the performance of the work for which this permit is issued, CONS RUCTION WE 101-00U-+118•,000 $243.00
1 shall not employ any person in any manner so as to become subject to the MECHANICAL FER POOL 101-000421.000 $24.00
workers' compensation laws of California, and agreeFthat -if.I should,become ELK.CT ICALI�.E —POOL 101-000-420-000 $43.00
3 subject to the workers' compensation provisions of„Section 3700,6 the Labor
erode, I shall forthwith comply with those, provisions.
- Pi tlilllT3Ts�Jfl 1<C�Is-•• POOL 101a00fl 19d0Qfl 1"100Date: Z rti ,01 ,L 14pplicant-
111111111 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.
r
IMPORTANT Application is hereby made to the Director of Building and Safety t~
for a permit subject to the conditions and restrictions sect forth on his >'
application. M-
1. Each person upon whose behalf this application is made & each person at MM,TOTAL CO)gST1((yr'y1ON A14D p �.2�1 11=ECK; $A96*9
whose request and for whose benefit work is performed under or pursuant to LEi1 PRE-PAM 00
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 z .ron :i.. M�.•Nihrms DuE Now $496.95
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 t
thg,'above-mentioned property for inspection-p'urposes.,.;:: '
Y / `� ✓ � „ am.�— r RECEIPT DATE BY f' F D FI LED+ ^ INSPECTOR
Signature (Owner/Agent)%,'`”
a.
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
forms & Footings
Ducts
Slab Grade
F—I
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
Drvwall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location 2 $
Underground Electric Z�
Underaround Plba. Test
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 I Encapsulation I F1 1-7 lexJ I r
Final I n?<J Cm 1 coo-111—
COMMENTS: oWN JS C C,L� of
Final
Utilihr Notice
I ELECTRICAL APPROVALS I
Temp. Power Pole
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice