9908-189 (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
.614611 CP
03131/20f
Date . Signature of Contractor J
OWNER -BUILDER 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).
O 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..
(Xj 1 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.
STAR INSI;:IR.ANC E Ci . 1 Fi I'1`1L"fYI
(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
sub'e`ct'to the workers' comer nsatiori provisions of Seetio'n" 00 of the a Labor`
Cod..., stia. orthwith comply it�ti�,o a provisjons. s. ^'
!date:
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,. 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 180 days will subject permit to cancellation.
I certify that f 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 here 'y, authorize representatives of this City to enter upon
thhe`above-mentioned p • pe`rty r in
fospecti rposes.
!Signature (Owner/Agent)-"^'=Date
C%
1 f BUILDING PERMIT PERMIT #i��
DATE } /C 'f ! VALUATION SUSAM -) LOT
JOB SITE 79-165 QIJAIL CROSSING APN
ADDRESS �C
OWNER
TRACT
CONTRACTOR/DESIGNER/ENGINEER
,k,ftN1SMELL1 CONSIR UC CION MCDITYR.E POOUS & SPAS
74-755 HIGHWAY III. SUMR4 105 P.O. BOX l'?9.!
INDIAN AVELLS Chi 92210 LA. QUV\'fA CA 92253
X760360 -3M CF3LP 1945
USE OF PERMIT
FOOL .ANIXOR. SPA
.(?O+J'L d"& SPA- ALARNI DARRIERS;RIALL M IN Pi_NCE AT PRE
PL t1,:5':( M I'cVtiPE MION.
POOL NN:1310P. SPA,
15,0(10.00 LS
]C: TUMA"B'ED
#;O.S—.1" Ok' d OfdSTR>tTC'°[I.ON
PERMIT FEE 9F MMARY
PLAN 4r,K?CIC 17t -E
S103-30
zWCiN'WMUC!'IONVEE•
101-0'418-000
$162.00
ME'CReASNICAL R.!'!E -- POOL
11012 4=421-000
$:24,()11
F' I.LT.tdll31:kF41i'fr P601,
161-000-419400
$27.00
S1:f1 401AJ.. CON STRUC't (ON.AND Ri., N CRECh
TOTA1. PERM I' FEES DUE NOW
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
(1.�,44C11�.4i0
53£3.30
$0.00
$363.30
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 Insulaton
Condensate Lines
Party Wall Firewal
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Hacks
Footings
Bond Beam
Electric Bond
Main Drain�`l
Approval to Cover
(sem
Equipment Location
Underground Electric
Final
Underground Pibg. Test
Gas Piping
GJ _
/ 6'
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Ou
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connectior
Encapsulation
Gas Piping
Gas Test
Appliances
Final
r�
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wirir!
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: