9905-090 (RPL)LICENSED CONTRACTOR DECLARATION .
d;l hereby affirm under penalty of perjury that I am licensed under provisions of
—01apter 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%E xp Date
Date + ' Signature of Contract, 4
OWNER-BUIL"DER 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.
(>e,) 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 Policy No.
S rikTE FUND 1*11, 03-"
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I, certify that inahe performance of the work foj which this permit is issued,
I shall riot employ any person in any a ner sold) t- 61 e subject to the
workers' compensation laws: of California, and agree/tl4at if I should become
subject to thp
rkers'corripensation pro7v"isionis of Sectio; 700 of the Labor
Code; I sh with comply with,those,p ovislons.�
Date: fC ' 'Applicant'' .. II/ % d f f• -
ti.
Warning: Failure to secure Workers' Compensation cov rageis unlawful and
shall subject an employer -to..criminal penalties and civil fi es 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_performedunder 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 1.80 days will subject permit to cancellation.
I certify that I have read this1application and Stateithat'the above information is
correct. I agree to comp)y'with all City, and State 1�ws relating to the building
construction, and: hereby authoriize representatives of this City to ent11 1,er up n
the above-mentioned%property for inspe tion purposes.
�4
;/Signature (Owner/Agent) +: ' Date
BUILDING PERMIT PERMIT#
�lli.5-.Qi4,14i
DATE ��?e4��%��'►VALUATION us,000.4)o LOT TRACT
s 7
JOB SITE
APN
ADDRESS 45-120 �kk,M.8i k,�'W�C:iB3+C.�B:tBt7'
OWNER '
CONTRACTOR/DESIGNER/ENGINEER 1
RICK & LISA 11AHC(,X., .
AMERICAN POOL CONS 1" RIU(7'1'ii7N ,
45120 RAAIBLEWOOD CT
7-1960 HIGHWAY i 1 i.
LA. QU1N'T..A CA 92253
PALM DESEIt " Citi. 92255-19
(760)340-25n CMA 11104
USE OF PERMIT
i OOL A.ND/01R SPA.
11001L & .5PA ONLY - ALi RMRS133AftRFERS 314ALL BE 114 PLACE' A`1'
PI H-PLAN11H. MPtrr:°r ON
POOL ANDfOR SPA 18,C+ O.00 LS
Ia1N.RAHT Fri,] . Sr.)Mr:ILARY
PLAN Ci-fFt-'i{ FUE 101-UU(Y4 9-318 $]22,85
ti
C. S Ri_f(7r.1 0N 17 i'1:, 10 140-4 1 R-W.O I P,{+.(XI
ILi,E3CHAMCAL ITE -- POOL 1.01-MO..42 R.-000 3243 (h0
ELECTIUCA L FEC -. i)WL 101-000-420-004 $45.00
k'1,I�Mtd1Nt�}rf�ks--POt�a, 101.-000-+dly-►�fK! �27.iN►
,
St B-Tf)T..A , CON S"°tRLIC. "RON AND PLAN l: l{I?c.:lti
LESS PRE—f-'AID FEES
T10,00
TOTAL PF.RMIT FUN OVENOW
15'44018S
4 l,�
EIP�
DATE
BY
DATE FINALED
INSPECTOR
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
Fireplace 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 YA
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 X71437 �Y
Gas Piping
Gas Test
Appliances
Final T --
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)
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