0010-135 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby-affin-ji. under p.9najty of perjury that l am licensed under provisions of
Chapter_9 (commenci}g with Section 7000) of Division 3 of the Business and
Professionals Code, and License is in full force and effect.
License # ',.' Lic. Class Exp. Date
t
Date fx^-.T.e>..4tsf,� Signature of Contractor'Ayt e_,b7,
C7
OWNER -BUILDER DECLARATION'" ' L
I hereby'affirm under penalty of perjury that I am exempt from the Confractorls
License Law for the following reason: ,j
( ) 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 offereoffor
sale (Sec. 7044, Business & Professionals Code). t
( .) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business `& Professionals
Code). j
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner t
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 y�'yytt may/ y Pullcy Nu
�.WLr+,`i,Lr�aF.•t0£Y Y'!J'� lr _�� 4' ®a7A.�Wii*Ui\}':7� ' ,
(This section need not be completed if the permit valuation is for, $100.00 or less).
O 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
Code, I shall forthwith comply with those p.owslons:
Date: -i : =F� , z�.�-�a Applicant
Warning: Failure to secure WorkerCompensation covefage 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, in
& 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 enter upon
the above-mentioned property,for inspection purposes.
_Signature (Owner/Agent)
?. /'�
-BUILDING PERMIT PERMIT# !
DATE/�').`/ r7�/ VALUATION - LOT (D_ ' TRACT
JOB SITE +•>
APN
ADDRESS
3-A*5 ,AiF_P .MA Oi' UARZ s
OWNER
CONTRACTOR/DESIGNER/;EN (NEER
53-465AYMNAM01;ATM7
2.3113 0,VIMxf MAV- J€:, RIMA
LAQi1WA CA, 9225:4
OKIMUO CA 91761
5240
F=
#
USE OF PERMIT
POOL ANIVafi. SPA
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POOLAxFDIOR SPA 61
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PIS OM y M, 101-000-439-31U $ n.A
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0 i ••(100.418-0 tS3.00
Oa�4101-000-418-000
CS'.PR C'TIZON MEE
ELEC'YIM;0FEE-- POOL 101 -000-42('e,000 �4�.fEE7
FLL.•'IUMBINO P99.. POOL. ' 10I-E?W-419-000
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RECEIPT
DATE
Bl^ ,
jj ?L'
DF E
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
r
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Ail
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L. 1
Grills
Fireplace T.O. ,.
Fans & Controls
Party Wall insulation -
Condensate Lines
Party Wall Firewall -
Exterior Lath
Drywall - Int. Lath
r
-Final
Final
POOLS - SPAS.
BLOCKWALL APPROVALS
Steel ,.- �.
`/��%�QO
5_E7
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
OX for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
/y
r
Gas Piping
Gas Test
.Appliances
Final
2/g 6l
(j---
Y
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)