0004-037 (RPL)M
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• LICENSED CONTRACTOR DECLARATION
I h 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
397252 C53 12/31/21
Date 44_-/9'jSignature of,Cont� to 4 ► �+
OWNER-BUILDE DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as ownei 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 STATE FUND
Policy No.
(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 Califorraia7 and agree tl) f if Ilshould become
subject to the workers' compensation1pr VISIO s of S 'ctlonw3r760 of the Labor
Code, I $ alsfort�wit comply wit phos pte�ons.
Date: 6 tt77 Applican J
Warning: Failure to secure yWorkers' Compensation coverage is unla ul 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 a City, and,State laws relating to the building
construction, and hereby authorize representatjv6S of this City to enter upon
the above-mentioned property for Insect�lon purr o7T21
Signature (Ow ner/A`gant)�J'�' ^-�' -2 ^ _(Date 1 " 6`0 s7
/
PERMITPERMIT# "
DATE/ VALUATION LOT OW4-0.17
TRACT
,1,b,13UILDING
JOB SITE I
APN
ADDRESS 45.295 CO7 DBIZOOX
_ -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
J01M.KMSER.
ST MA18POOLS
45-295 COWBROOK
P.O. BOX 835
LA QtM4TA CA 92253
PAIAM DESERT
CA
92261
(619)568.4014
CFfC4
.529
USE OF PERMIT
POOL AND/Oil :SPA
POOL & 5PA ONLY-AI.ARMSMARI:IERS SHALL 89 IN PI..ACE AT PRE
PLASTER MPECTION
FOOLANDIOR SPA 13,100.00 LS
EWMl.1'ATED COW OF CON STRUC'1 TON
15,100.00
PEP -MIT lid S'7:7&D:IV1'.hRY
PIAN CHECK FEE 101.000-439-318 5911.15
CONSTRUCTION FEE 101.000-1118-000 $171.00
MECHANICAL FEE -- POOL 101.000.421.000 $24.00
ELECTRICAL PRE •- POM 101-000-420-000 $45.00
ftumwm Yin, POOL 101-000-419.000 $27.00
-'
• ,�
:SUB -WEAL COWS"1RUCTIO14 AND PLL CTIECK
W8.15
LESS Pn, -PAID - "
$0,00
TOTAL Pk'£dt IT ISS 13U7E NOW
$376.1:
RECEIPT
DATE
BYj i
DATE FINALEO
INSPECTOR
t /
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 Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOL`S -SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
�D
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
9
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
30 z5a
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: