9612-158 (RPL)" LICENSED CONTRACTOR DECLARATION
I hereby affirm�under penalty,of perjury that I am licensed under provisions of
Chapter 9 (commencing with mention 7000) of Division 3 of the Business and
Professionals Code, anifmy License is in full force and effect.
License # Lic. Class Exp. Date
��.y�j
f '
Date �/3 'Signature ofIContractor A/A
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 the 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 j
I hereby affirm under penalty of.perjury one of the'foilowing 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
pe¢,ormance of the work for.which this permit is issued. =
N 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 M113 E`X3,1df
(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
Cjode, I she(Il orthwith comply with tho��a provisions.
%/Date: ��° ��-� Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of Compensation, damages as provided for in Section 3706
of the LaboriCode, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
•1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees 1%
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
/thabove-mentioned property for�inspectlon pu poses.
ature (Owner/Agent) ��'r %/a Date +�
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PERMIT # CONTROL #
BUILDINGPERMIT
4555
DATE VALUATION�19'3��tI� LOT ' TRACT
JOB SITE
ADDRESS 79-0440 HIVCH HO,idI.,
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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r:�^1W. 90,X171411
1.,A. t11J$:N''1'A. 451;b.�3' :
LA. QU6.IWA CA 9225:3
(61, 601-:3585
USE OF PERMIT
PO ff..3b S11A.ONLY
POOL -XND Ot4,`3PA. tG,t?(sUv�3L L
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'.E"'PT8NATED C �'i' OF > ONMNTRU T$•ON
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19,1600.00(.
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P.1:,AAf+I'G3-3;i?CKFf�� 101-000-439-318 57h.U5
C*ONST`4III rT01: T010 ON N 1T? 101 -000 -418 -OM � # 17.t7f►
MCCHAN1 tU,-FIAH :• P001, .101-000-421-000
.RLEC i TICAL FI -4#00L.' L. J o i -000-420.000
3` �s..UmlYNO14.1T, POOL 1.01-000-419-000 5127..00
PXY7 AND PLAN CHE.0 K
$�f39.ds
c� .ESS �'la-•1�t1.t.!?.1F,E1:
\frAL
�P PERWT-rE S DMIK NOW
$28919
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
_'2.• r
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roaf Deck
O.K to Wrap
ming
Im-lation
Fireplace P.L.
Fireplace T.O.
Party Wail Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage'
Fixtures
Main Service
Smoke Detectors
Temp. Use of Power
Notice
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
-9 r7
Set Backs
Electric Bond
5,1
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
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Final
Gas Piping
lf/L
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
I Equipment Enclosure
Shower Pans
I O.K. for Finish Plaster
Sewer Lateral
I Pool Cover
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage'
Fixtures
Main Service
Smoke Detectors
Temp. Use of Power
Notice