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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjur;��that -am licensed under provisions of
Chapterl�,(�_mencing with Section4ibbO) ��oDivision 3 of the Business and
Professionals Code, and my License is in full Gr�ce an"d' 'effect.
License,&j,., Lic-Class Exp. Dat
k A05111,46
Date 6' _W, ', b 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:
( ) 1, 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Busines.s & 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 370MfithpMbor Code, for the performance of the -work-for which this
V I otn A . .
& policy no. are:
permit is lssuej.'�y 1wNj1o"rkers' compensation insurance carn6ir
Carrier Policy No.
(This section need not be completed if the p
I certify that in the performance of the
I shall not employ any person in any.man
workers' compensation laws of California;
subject to the workers' compensation pr&
Code, I shall forthwith comply with thosWki2
Date: -14 Applicant -
4"
valuation is for $100.00 or less).
for which this permit is issued,
o as to become subject to the
agree that if I should become
s of Section 3700 of the Labor
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, indemnity
& 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 ap
correct. I agree to comply with
construction, and hereby auth(
the above-mentioned property i
Signature (OwnJ�/Agent),'_1__/
and state that the above information is
and State laws relating to the building
resentatives of this City to enter upon
on purposes.
RECEIPT. DATE BY
DateA/_ �11111_1601
PERMIT# CONTROL#
-BUILDING PERMIT 204'
4
DATE VALUATION LOT' TRACT
JOB SITE ...
ADDRES . S Ca s4r-CA no 4X LV_
APN
I .
OWNER
CONTFYACTOR DESIGNER / ENGINEER
CALI V1011,1411 A POOLS;& SPAS
RG. BOX 1,716
BOARLAV.1-%LK dA2
1A QUINTA CA 92,01'�:4
PALM ONSERT (,A, M60
66 19'071 -1941
019)"140-90M ;55
USE OF PERMIT
P001, ANf� SPA 4`_)NLY
'0JU 1"r.15 Oti A,7* L 0 A
COST OF, CONLIS11RUMAIGN
11,040.60
P 11,1; H M VT VE, C 8 1 J N1 N1 A 14Y
Pow ctfrck� vull
fit W,13i N,'Al. II1"It" KXA, 10 140)41040)
(ZOONSTRUC-110N AND PLAIN 01VCK
'SS PKE-PAID FEES
T07f.M. PERMOTF.MNOM, NOW
DATE FINALED _T
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
I DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
ForIns & 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
ireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
t�rty Wall Firewall
Ekterior. 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
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Wal,qr Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sh9wr Pans
O.K. for Finish Plaster
Se%3r 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 Voltne Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)