9903-099 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under pro,-�_-onc o ,
l Chapter 9 (commencing with Section 7000) of Division 3 of the Business andel
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
/o R028 C53001/00
,-'Date 3 Signature of Contractor
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).
( ) 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.
(, ) 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.
STA L i"MM %$6.93-t)fi(Tt:N-1u
(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 agre�efvt�at if I s0ould become
subject to the workers' compensation provisions oSection O of the Labor
Code, I shall forthwith comply with those proviidns!r
,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
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 repres ntatives,,gJ this City to enter upon
the above-mentioned property for insp Vo
n �Date
,/Signature (Owner/Agent)
PERMIT #
BUILDING PERMIT ygp,3049
DATE 7 VALUATION S14Nj} g) LOT 15 TRACTJOB SITE'
SI
ADDRESS 149_055 Hi0 t1,3 EN030 APN 64[}-331-007
OWNER CONTRACTOR / DESIGNER / ENGINEER
T 1) C'ALIFORNIA POOLS
VQ, 13U\ 1710 7.1-77.5 JON1 DR1ti'E, ##A
LA,C,ilJINTA (.'A 912;3 PA.LIM DESERT ('A 92260
(7601340-0000 3"
USE OF PERMIT
PCK--il, ANDiOR SPA
P(AX r#ND S1 YL of t.l
v.
PAID
AR 0
11001*. MD.Gii SPA.
14"W,00 LS
i;,N7'lHATED CONTOV CO T—.'S"t'Rt)c'1;ION
14,nf).00
IG'3r�Ml! i�I;�::ftft�sR'}1>,lti'
PLAN C't1Ti('K YUP
10 418
S10% orf
('<>N50141IrTf0N 14-T,
1103 -MY) .419-000
151c, ()r+
NliiC"IW41CAL FUL •-!FOOL
101-000-121-000
GiFA,iRICrpt.i,U3--POV1.
I01-t}u(?A -U00
PLU"41NOT= EE -- I}1)ui,
101 -000 -419 -OW
S-17 IN)
Ct f 1;-1(Yf'{� C , t't')NCI'1� (tf 110N A N F) P1. �1 N C" 11 F± (' K '�3hZ 'i►
1-0 FAL PERM IT {+h.RS 01!C NOW 1 $343,341
RECEIPT I DATE I BY I DATE FINALED JINSPECTOR
,r
:INSPECTION RECORD
ti
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final I I
Gas Piping
Final
Final
Electric Final w
Waste Lines
Heater Final
Water Piping
POOLS - SPAS
BLOCKWALL APPROVALS
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Steel
Set Backs
Encapsulation S
Electric Bond
Footings
Gas Test
Main Drain
Bond Beam
Approval to Cover
Final l ..
Equipment Location
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test _
Electric Final w
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 S
Gas Piping
Gas Test
Appliances
Final l ..
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice