9903-228 (RPL)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 Date
r' $612$ G53 V00
„Date 3 2 �j Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty sof 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
( )' 1 certify that in the performance -of the work for which this permit is issued,
i s. iall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree t9-Wf' I should become
subject to the workers' compensation provisions o Section 3700 of the Labor
Code, I shall forthwith comply with those provi io
Date: 112qll J Applicant
-
V .
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 represe tfivedof this City to enter upon
the
above-mentioned property:for inspe do p roses.
Sfanature (Owner/Aaentl >' 'J�i _ Date 3 3 �tf %
4 d
BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
3/2 419 9 $16190.00
JOB SITE -9 �y p9 p
ADDRESS j _519 CO3.t,(Aiv.VAL
APN
».
OWNER .
CONTRACTOR / DESIGNER / ENGINEER
l:SL LAM It CORPi3CLAMON
C.t>;i..dr-ORMA POOLIS & SPA;S
55.920 PGA .131 VI)
74-72.5.10M O1 IVE, #A
LA(,ULn_ FA. CA 92253
PALM, OESEXI' CA 92260
(mo)-mo-9wo CK -0 iii
USE OF PERMIT
POOL A.NWOR SPA
t'GCii , 11MA.4: i3 Q. ti%. i&,13A.RRHR9 SHAD, BE.R tI LACE AT
VS9_°J1% t'kTF`d.Di.'OS'ti''OV CON STg i1MION
6,900.00
PERMIT VER SWUN'IARY
)end.ANr.'RE CK7r':a, ,iII-OUO-�1'� 3ItS $i.i'T.i1U
4' oNkl rlkf J01f FEET 4,01-00041,8-000 5180 0
MECHANICAL -FIs — POOL lol woot)- •421-000 rw1.00
:1IE(Z ii RICAL FETE -- P0QL' 101-t?OU42"00 $45.iAi
PLUN1131.c* € w, -- Piytyl. 101-000-419-000
SUB-IT-TrAr. AND MAN CHECK
', E'.tS PRx:-4'.UD IFE1:S
$0,00
'?'OTA. Pii,"Iff"IFTI s 013x, NOW
5393.410
RECEIPT
DATE r_ -
BY f
DATE FINALED
INSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
s
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
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)
FROM CALIFORNIA POOLS AND SPAS PHONE NO. 7603465407 Mar. 23 1999 05:28PM P5
r.:
oGD
IRCITY
,
Lq
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BUILDf,& SAFE p »-IL
CONDITI AL
ACCEPTEDFOR NS UGTIO /
�A SUBJE0TT0INSTA LATIN AS PER
AN. ALL APPLICA BLE C ES