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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�
AL
DtoSignature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury6 at 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
s.
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
pel•ti`ormance 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 STATE FUND Policy No. 229-00-0019334
(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' c061
p�As�tion laws of California, and agree that if I should become
subject to o kers' compensation provision of Section' 3700�f the Labor
Code, I o with comply with thodprouisions.
ate �•- - Applicant U -�' 4' _,/
arning: Failure to secure Wo ers7Compensation coverage is unlawful and
shall subject an employer to cfminal/penalties and civil fines up to $100,000, in
addition to the cost of compgnsation, 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 representatives of this City to en r (on
the above-mentioned property for. inspection purposes._
Signature (Owner/Agent) ter_ .��'? Date;
BUILDING PERMIT PERMIT#
DATE VALUATION ^u5 {W00 LOT TRACTJOB
S° ► �a . _
SITE
ADDRESS 4"15 COLDRROOKJ ANE APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
Y-WSEY iTAL HAM IMM Ciba VACAnOW POOLS
45-315 COLD }ROOK LN 9522 DO14AI SON RD,
UV Q"I:iIFTrA CA 92253 WdER TE VAU EY CA 412356
MA
#6% �'BT 433 5 ,
USE OF PERMIT
POOL ANWOR SPA APR 0 3 2000
POOL ASPA ONLY - ALAARMSWATdRIERS SHALL BE rN PLA ' Q�J1 IINTP
PRE -PLASTER INSPECTION V 9
VALt1A.!' ON 1 ,000,00 LS y
ESTII"TW) COST OF COl,NSI'.R`47C'flON 1511(00 00
FEau= FEE SIMOVIARY
PLAN CHECK, � 101-000.439.318 $105,30
CONSTRUCTION FF:E 101-000.418-000 $167.00
MECHANICAL IEE -- POOL 101.000-421-000 $74,00
ELECTRICAL FEE -. POOL 101-000-420-000 $45.00
PLUM81ING FEE - POOL 101»000-419-000 $77.00
Si7B-°1'OTIAL COMTRUCTON AATD PLAN CHECK 1363.30
1490 PRE -PAID FIM $0,00
TOTAL PFR142TT YEES DUE NOW $363—V
RECEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 Plbg. 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
Sewer Connection
Encapsulation
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: