0207-019 (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
65 6128 C53 Bic C-8 11(9/31/2(
'Date Signature of Contractor
i
e� OWNER -BUILDER DECL A, ION�� .t
I hereby "affirm under penalty of perjury that I aVmptfrom t e ,ontr ctor'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
I hereby affirm under penalty of perjury one of the following declarations:
jO I have and will maintain a certificate of consent to self -insure for workers'
tcompensation, as provided for by Section 3700 of the Labor Code, for the
'performance of the work for which this permit is issued.
(A)7'l 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 worke"rs' compensation insurance carrier & policy no. are:.
Carrier 0T,,ff,TE OO9t,11'E;NOAi`1 Policy No. 0460DO6168-DI
(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 shall forthwith comply with those provisions.
�
' .D'ate: Applicant
Warffin .Epi(y?e to secure Work S;, Compen ation<coveral Is unlawful and
sha(subject an -employer to crimiHal: �aaltle�and vi,'nAtu rfo $100,000, in
r addition to the cost of compensation, damages asp vlded for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is.hereby made to the Director of Building and Safety
for a permit subject ..to the conditions and restrictions set forth on his
;. application. '
1. Each person upon whose behalf this application is made & each person at
whose request and for whose ,benefit work is performed under or pursuant to
any permit issued as a result,of this applicaton agrees to, & shall, indemnify
& hold harmless the City of/La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from dater• of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent), Date
}
PERMIT # '
BUILDING PERMIT
DATE VALUATION LOT. TRACT
JOB ADDRESS
APN w .
OWNER CONTRACTOR / DESIGNER / ENGINEER
1'D 0r, S T11'r D .ti C;l.CsFlbMN1r SSC K)F;?+ Ik P00w, & SPAS (Toy; - 3 co
747215 JOXI'DgP�A, OUXIB NA
PO BOX 1716
i,.,o-'4 92253 F'AL1E1/iD:F$iER T' CA 92260
USE OF PERMIT
3?Oi lr-. AN 01i. J? aa.
PRIG TO PRE - RASTER 1NS1sF.0 TlIaK
POOLANDIOR SPA
21100.00
y� 1 �'+{,q {,yg �y )GAS'MA COS:r Ole C�;►.i'��'.X �'C'�1,4TN
PLAN CHECK 17U, 103 �000-439-318 1 $140.4
A1S?t°,kIAN1cAL Fn -- P0, OL 1.01.000.421.000 sx�.oq
9,LX ,;TRRC,t I1 F&tr .r FOOL 101-000-420,.000 i �3.Qt1
My BkE►1' O ME, -- POOL ; 101-000-419 00113 00
`P
SU
RECEIPT DATEBY
DATE9FINALLEED .
41441.40
$0.00
1
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
- S —mom
Set Backs
Electric Bond
Footings
Main Drain
/:3r
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_-7,e— -U
Underground Plbg. Test
_ —) & - p
Final
Gas Piping
- Z4. -
PLUMBING APPROVALS
Gas Test
Electric Final
-fib -FEZ
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
FbQures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: