0110-202 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under lienalty of perjury that I am licensed under provisions of
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1-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
U) and effecO
C14 LLJ Profesiionals Code, and my License is in full force ,
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License # Lic. Class,,., Exp. Date
)'417 ic f) Rip 7 112
33
LU ,C.ti
6 _Z r- ate —.,Signature of Contractor
I.– C) OWNER -BUILDER DECLARATION
• U.1 W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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, Business & Professionals
Code).
( ) I am exempt under Section —, B&P.C. for this reason
LO
C\1 Date Signature of Owner
O C\1
< WORKER'S COMPENSATION DECLARATION
Z .1 hereby affirm under penalty of perjury one of the following declarations:
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0 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL — compensation, as provided for by Section 3700 of the Labor Code, for the
0_J < _J performance of the work for which this permit is issued.
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< U 010 ( ) I have and will maintain workers' compensation insurance, as required by
O 0 Section 3700 of the Labor Code, for the performance of the work for which this
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0) permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Cartier ',417ATERN,D Policy No. X29-0012+' s
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< (This section need not be completed if the permit valuation is for $100.00 or less).
_J ( ) 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 thatlif I should become
It ,^. I? i�l - 3700 of the Labor
subject to the workers' compensation prpvistog't of Sectigh
Code, I shall forthwith comply
Dat' P�_ 19 1 0 11
Date.` — Applicant
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
4
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 lawg relating to the building
construction, and hereby authorize represent9iiQ'S--ofthis City to enter upon
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the above-mentioned property for.4 inspection' purpose�l. QN 0/ C I
Signature (0 wner/Agent)
Date
BUILDING PERMIT PERMIT#
DATE VALUATION COT TRACT
I On. arix $Is,0WA)G 2.7 1.11)
JOB SITE 4'
ADDRESS W_-4
� qO PASWO DEM REY
APN
604-M _009,
OWNER
CONTRACTOR/DESIGNER/EN INEER
KEWN JDARCY
cal.1's-mucri'low
79-380 PA M-10 DJTJPEY
74366 VELARDO TO
LA Q-UNTA CA 92253
r1ALM DRUERI" CA 92,260
(76.0)773-3293 Mu, 5 t0.2
USE OF PERMIT
POOL'ANNOR,apx
,POOLWACATS' SA.'ND ALA.9MSTO BE IN P1 ACE PRIOR T()
PR&PLASTTA. I INRPNCTIOKi POOL EQUIPM0.10 ENCU)SURP, N.OT
POOLANDIOR UPA
PLAN 0RECK FFIX
C034!rf R1Jr'TKn4 PEE 101--OM418-000
MECHAVICA1, FrKE POOL, 101 -NO -421-000 S24, 0 0
A 77, - POOL
S27.00
OCT 18 2001
CIFIf OFLAQUINTA
"UAmds= nr-PrT
SUD, 'rM*AL CN324M U10TION ARD PLAN CIMCK
Z
LESS YRF-PAID FEEZ
P.W,
1'0TAL.PPMWf FUS DUR NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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Ir,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
f
JBUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs i
Underground Ducts
Forms & Footings'
Ducts
Slab Grade I
Return Air
Steel I
Combustion Air
Roof Deck 1
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing l
Compressor
Insulation }
Vents
Fireplace P.L. I
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath I
,
Drywall -Int. Lath'.
j
Final
Final }
POOLS - SPAS
Steel V •�2 S=v1
Electric Bond (�
BLOCKWALL APPROVALS
Set Backs 1
Footings 1
Main Drain
Bond Beam I
Approval to Cover J
Equipment Location 1
Underground Electric
_
1
I
1
Underground Plbg. Test
Anal }
Gas Piping
_
PLUMBING APPROVALS
Gas Test
--
Electric Final
Waste Lines I
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral I
Sewer Connection
Pool Cover
Encapsulation
Gas Piping I
Gas Test j
Appliances ]
1
Final
COMMENTS:
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Final )
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures I
Main Service 1
Sub Panels I
Exterior Receptacles
G.F.I. I
Smoke
Smoke Detectors
Temp. Use of Power
1
Final )
Utility Notice (Perm)
CONTRACTOR cannot assume !resDonsit�lity for -: GENERAL SPECIFICATIONS - -:
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-damage-to-curbs.zi .-' riveHrays, cement
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Address:*l�
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_POOLS SPAS • LANDSC PE�
_ -- - = - - - - - ----- - )773-3293-- ---
7, 74360 o Drive
Wk. (760
__..._.� __.� x _..-_--:.__._________�.:-..._.....�---_.____.._ _..._ ._. ..._,.__._. _ ._ _._. ._._._.._.. _.._ .._-..—�-.-:-_. ._.._. _.._ ..._ _._ _. _ -- --.,..�_— ___• Fax (760)773-3293 .
Polm
Desert. CA 9 60
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