0303-243 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 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 # Lic. Class Exp. Date
656128 C53 Hic °8 �y 1W31IN
Date 3 or p Signature of Contractor
d
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 issued. My workers' compensation insurance carrier & policy no. are:
Cartier SPATE COTy1?'YNSA`? 1 Policy No. 046.614-8-3063
(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-shII forthwith comply with tfi s'e provi 'ons.
Date: Applicant -w-r -�;z,
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.
3
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 o inspectionrposees.
Signature (Owner/Agent) - - Date 2-2S c�3
v
PERMIT #
ING PERMIT
0MI-143
DATE VALUATION �.r f LOT' TRACT
i r
JOB SITE
ADDRESS 79k-420 DRti{3KMILLE
APN - -
OWNER
CONTRACTOR/DESIGNER/EN INEER
M DES.I�W Drs°JI LOOM& i
CALIFORNIA POO :il S & SPAS' (I -OP MAW C0
PO BOX 1716
86.100 A'V:EtTURP 54
L%. Quraym CA 92253
COA,t"MAA CA 92236
(760)598-9222 CBLO 00355
USE OF PERMIT
POOL A10VC9R SFA
a .a•t, 130Q (t4 J L.. 19 AVtb i ±elf :v.) .r'r e%t PI
111 PLACE AT PRF. -PLASTER INSPECTION, EQUIPWNT ENCLOSUR , NOT
114CI, UDED.
Pt)OL A)IDJOR SPA 2#,QOA,flO Lf9
:-l'.1~Y'nc6A3:13M Con 'Clip Ct'M`rRuLl,WON
23,000.00
1,22 M rr FE R 1.9U& i�9C.AHY
PLAN CHEMFEE 101-000-439.318
CONSTRUCTION FEZ 101-000-418-000 $234.06
11' 1EC'lMkEi:'AL, IFEP> -•' POOL 101.000.421-0047 $24.00 .
ELECTRICAL "X — POOL. 101-0004,20-000 $45.00 '
PLt11d1131' O 'R. Z -- POOL 101.00, 4.19.000 527,00
suB.-T07 AL, (,,o 1FtL .C7,,t iot; AwD PLAg L%: 4-r
$482,10
1.1188 PIM -PAM , , '.
d
$0.00
14AR 2
CITY OF Lei QUIN^ A `f
FIf1Bf41 !Ch -CL -,PT.
RECEIPT
DATE 7 r'
BY : 'fJ /
DAT FINAA�1LEED L/
INSPECTOR
RID
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS I MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fomes & 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
Water Piping •
Exterior lath
Plumbing Top Out
nrwunll _ Int I ath
Shower Pans
r"'a'
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond i
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:
rmas
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
TemD. Use of Power