0104-114 (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.
L'ic'ense # Lic. Class Exp. Date
Date " 6fgnature of Contractor { r
{ jdp.d(OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that l 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).
( ) 1,, as, owner of the prgpertv, am nxnlnSively Contracting with liacn9ed
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 wol,k•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.
TATE w'#MPENSATI iLY tffldlG
(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 agree that if I,should become
subject to the workers'. compensation provisions of Section 3700 of the Labor
Codej-9hall forthwith comply, with those provisions,
1Z g'l g12 V1. �111Applicant
Warning: Failure to secure Workers' Compensat on 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..) 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�eql, inspection purposes.
Signature (Owner/Agent) '• �'✓'` �' Date
- "BUILDING -PERMIT PERMT#
DATE y.. VALUATION LOT 0:4104-114 TRACT
0+113/ ... $20,140A0
JOB SITE I APN
ADDRESS5. .9MAMIDA)RAVARRO
OWNER CONTRACTOR / DESIGt 'R / EN (NEER
:ft'���1S('�k�i �LEiC1'VRI�IA POOL $& 9S"1+1� d"C+11"C).i
53-960 AV MMAXAVAW 74725 JONI DRIVE, SUMP—MA
LA QUMA, CA 9220 PALMEREPT CA 92,260
USE OF PERMIT
MMMMM4. POOL.'fQUIPk ENT MCLOOM& NOY INC--- LU'r3 D,
15U41'rIPLOPANCl�i�` 4f3cu•G1'i Y'`"fthF�kl�[t!�
POOL ANDIORvQkA
1890$,00 LS
4 int'.. WALL
%$:i3E3 lly
MIW,fMlt"AI,FEK--POOL
101--000.421.000
�ii�4.6n
&LECTRcICA&L FYZ — POOL
101-M-420-000
$45.00
PLUMBitNO RIP _14001L
101-1000-419-0(K)
W,94
.PLAN CHECK K PRE
S10.40
€`.t rT31TRU'C'TIC RE
I X31.00K�0 i X3.000
$2.1.6.00
TAI SS k'RrK-,Pl FJ_W iib.00
RECEIPT UATEBY DATE FINALE / 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
Set Backs
_
-6--t-0
Steel
Electric Bond
_
Footings
6_
— t '_ d-� 5?
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas PipingVY
5�
PLUMBING
.�PPIr20VALS
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
/.0(
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Pov+.r Pole
Underground Conduit
Rough Wiring
Low Voltag-elfAring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)