0206-089 (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
AS 6128 I� '»8 104:31 /2(
Date Z. + 'ell Signature of Contracto f�tc / .,�/J
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's'u
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:
Carrier uTfATF. O3V.ipaSAT) Policy No. 0460001U-01
-w3I
(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�visions of Section 3700 of the Labor
Code, I hall forthwith comply with thp. se�provisfons.
Date: - l Applicant {` ,b. 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
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
F'EHMI I N
,fE LI)ING PERMIT I#
DATE 06-089
`VALUATION sYs ,i LOtf 45 TRACT
fir':" s�+�...
ADDRESS 9 .
-4145 OROOIKYA IIaE APN
OWNER
)�"M s011tcz&MI S
7 -%- y3S,groo h -w Ili
I A.C,), C4J
9W53.
USE OF PERMIT
I)OO .. X10%. SPA
CONTRACTOR/DESIGNER/
74=5 70N1,D11rF_, M= #A
PALM DEWIRT CA 92260
(760)340-9000 M-11.411. 00,455
POOIJSPA,.ALARd4IV13AfiRIZItS:s'H U,BEINPLACEPRI01tTO
PILE-Pt."M INSPECTION
POOL ANIJOR SPA
15,000,04) LS
�..r'9w1"MAT91: COST OF con9I:;i%1.fiO'I,TON 15, .OD
PLAN FEElit ^Cx(30a4419.31 R 110130
CO'N 5TRLWITIO N M 101.000-418-0'00 S162.00
SUCil' ICA1., RE -• POOL 101-000-420.000 SASA
PJXfAbfl40 FEE .. Pool, 101-000419-000 12 7.00
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on hi ' O
application.
U
1. Each person upon whose behalf this application is made & each person
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemni
JUN 13 1��7
& hold harmless the City of La Quinta, its officers, agents and employee
lJ
2. Any permit issued as a result of this application becomes null and void f ZWY
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellation.
FII OFLAANCEUIN
FINEPT
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 aut orize representatives of this City to enter upon
,the above-mentioned propeP for inspection urp se a
Signature (Owner/Agent2 � �� Date
RECEIPT
DATE
4.,O 4R 17,d01�d�7.. 0 YVASJt1L` �"I'lil.30
1=1�41As
$0100
TMMI plaz rim :tl'Si3+IS D'U NOW $3.39„311
BY DATE FINALED INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings — y
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
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
_
Main Drain -
Bond Beam
Approval to Cover
_
Equipment Location
Underground Electric
' Final
Underground Plbg. Test
Gas Piping �p—,Zsr—o2,
S
PLUMBING APPROVALS
Gas Test as—p
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
0
Fihal
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: