0201-023 (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 Exp. Date
B
ate !Y Signature of Contracto,�4/
OWNER -BUILDER DECLARATION
I hereby affirm underpenalty of perjury that I am exempt from the, Contractor's
License Law for the following reason:
1, as owner of -the property, or my employees with wages as their,tole
compensation, will do the work, and the structure is not intended or offered for
sale (Seq. 7044, Business & P(6fessi6nals Code).
1, as owner, of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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 followi6g declarations:
1 -have and will maintain axertificate of consent to self -insure for workers'
compensation, as provided' for, by Section 3700 of the Labor Code, for the
performance of thew6rk for which; this permit is issued.
(\.)/I have, andwill; Imaintain, 'workers' compensation insurance, as required by
Section *3700 of the Labor Code; for the performance of the work for Which this
P4,rmit is issued.; My Workers' compensation insurance 'carrier & policy no. are:.
Carrier Policy N6.
STATEFUND
(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 sligllltnot employ any person in any mariner.so as to become subject to the
workers' compensation laws of California and . agree that if I, should become
subject to the workers"compensatio q�rovisions of Section 3700 of'the Labor
Code,, Is all orth1with comply wi mos provisions.
°Date,: Applicant
Warning: Failure to'secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100;000, in,
addition to the cost of Compensation, damages as provided for in Section 3�O�619
of,the.Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the' {conditions and restrictions set forth on Is -
application.
1. Each person upon whose behi "ble'�& each p-.--. i.irlit
behalf thi� appli6ation is ma
16
whose request and for whose benefit work is4performed,'Linder or pursua t to
any permit issued as a result of this applicatdn agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, 6 1. ents.and employees..
1. Any permit issued as a 'result of this application becomes null and •void if
work is not commenced within 18*0 days from date of issuance of 'Such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all'City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prope,rtylrdrinspection purposes.
Si ri-t-ra (r)wner/A Xte),' 0Date yd/
PERMIT#
-PERMIT
LOT TRACT`
7 VIOM
JOB'S`ITE
ADDRESS.
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
'A'A%
CO.111 11111"O"iff BOMB
1 53-705 MTNTIM
5137 0 ANIMMA-D FKRY1LTDk*
UKhk CA, 92,25 1
1 A ('MCLA. CA 92M
C;6q)569-1.404 CIPM 6erJ
USE OF PERMIT
POOL ANDJOR
1<60L QNL 1r.N6.1i.EA1'LP0_- ALARM St"JZRIERS, SHA14, 'BLY. IN PLAC?
'
PRIM TO P006 R09fRAMT 140T
INCLUT)KD 114 PERMIT.
POOLANDICA SPA 7,090,150 li
EMMAIED COS, Clorwraveliols
7,mm)
VERVUr 11110! SMENTARY
PI'Alq clacr. FEZ 101.000-439-318
CON-$TRUCTION F&E, » eo I -o 0 -a-1 I (W
9L&dT.T1JCAL YKE -- POOL 101-00-0-420-000X5.00
'PLUMBING 11U, — POOL I ot-000-4 I f0-000
APR -1 0' 3 2go?
JUIRA
C19 6 PF
10 C OKI STRU(2TIOR AMPLAN Mitt C -K
$22om
tsom
TOTAL in M., F.'s- Du
aam -R. mow
S,220m;
�RECEIPT
DATE
BY
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.
Grilis
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Footings
Electric Bond
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
Plumttng 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
Vow Nottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: