9904-228 (RPL)LICENSED CONTRACTOR DECLARATION
I'hereby,affirm under penalty of perjury that I am licensed under provisions of
Xhapter5'(commencing with Section 7000) of Division 3 of the Business and
Professiorfals Code, and my License is in full forc6 and effect.
License #'.- - . Lic. Class , Exp. Date,
�2-75-796 C-5-1 C-8 12131 MA
A)ate ',�XY Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Li6ense 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).
J: as owner of the property,: am. exclusively contracting with licensed
c6ntractors,to construct'the project (Sec. 17044, Business & Professionals
Code).
(.)`1 am exempt under Section B&P.C. for -this reason
D.ate, 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 wo,rkers.
compensation, as provided for by Section 3700, of the Labor Code, for the
performance of the worWfor'which this permit is issued.
.-qSLI h�ave.and will maintain workers' compensation insurance, as required by
S�Mct& 3700 of the Labor Code, for the performance of the work for which this
permitis issued. My Workers', compensation insurance carrier & policy no. ,are:
Carrier Policy No.
4 1203 25
(This Section need not be completed if the permit valuation is for $100.00 or. less).
I certify that in the performancei 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'bf. California, and agree that -if I should become
bje6t to the workers' c6mpdnsati6n provisions of Section'3700 of the
/tabor
'll forttf
Cede, I shall 'with comply with those 6vidons.
t . v ll Z'
Pa e . 4�fl,2 P`,62 , Applicant!--�-
Wirning- Failure to secure. Workers' Compensation coverage is unlawful and
sh a11 *subject an emp!6ye.'r'to criminal penalties and civil fines up to $100,000, in
addition tothecost 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
for1 permit subject to. 'the conditions ' and restrictions set forth on his
.
application.
person
Eac i h up6fi whose behalf this application is made & each person at
4h6se request and for whose benefit work is performed under'oIr 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 applicationbecomes null and void if
work is not'commen6ed 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 1, have read this application and state that the above information is
correct.'l 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 _
for inspection purposes.
?Signature, (6vner/Agent) Date.
PERMIT#
BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 44-794) CALLE PLACIDO
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
FRANKLIN RES1131?NiCE
C. H. POOL CONSTRUMON,
44-790 CAUE PLACIDO
6113-463 PERE?.. RD.
LA QUINTok C:'\ 92253
CXf HE'D RAL C nY CA, 9723.4
-
C/6(D)128-241 CBL.# 69
USE OF PERMIT
POOUSIW�, iV,,A",81.0AHRJMRS SHALL BE IN AT FR&KAST01R.
.[N8PlXF10N.
P001,, ANDANt SPA. IZ,500,00 LS
ESTIMUIED COSROF
PLAN Cf it FEE 101-O(YO-439-318
S144.00
IVIE CIR.XIMICAL FUIX S�A44:ot)
FARC TR1CAL.FH-E P001, 101-00-1-420.0oo 845.60
PLUMBY140 MTE PICY-111L 101-0ilk-4,19-000 $27,00
SU-PrWrAl, GONSTRO M -10N AND PLAN CHUX
&I
LESS PU.-ANLIFEFS
$0,00
TT 1 AL 1.11ERMIT FERSIMENOW
RECEIPT -77DATE
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
BLOCKWALL APPROVALS
POOLS - SPAS
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
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover 17
Sewer Connection
Encapsulation 10
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
LL
.4
--4
7
5,
G.H. Pool Construction
r CA 82234
3
dtA
BUILDING S., %E-311AFETY DEPARTMET
CONDMONALLY
ACCEPTED FOR CONS"RUCTION
SUBJECT TO INSTALLATION AS PER
AND ALL APPLICABLE CODES