9603-138 (RPL)LICENSED CONTRACTOR DECLARATION
U) 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
N W Professionals Code, and my License is in full force and effect.
p :D c,) License # Lic. Class Exp. Date
w - 656178 C-53 1051IP6
r-
Z r,1� Date Signature of Contractor,
T Q '1
0 OWNER -BUILDER DECLARATION
CD
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ Il License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
Ln
N Date Signature.of Owner
ON
O)
d Q WORKER'S COMPENSATION DECLARATION
p 2I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W u- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il � Z permit is,issued.f�lyworkers' compensation insurance career�&fp,ofiy no. are:
Carrier Policy No.
ab D
J
(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
Code, I ` all forthwith comply with;those provisions.
Date: 4? ° t' 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 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 1180 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 al`City, and State laws relating to the building
con lm tion, and hereby authorize4epresentatives of this City to enter upon
the above rationed propert fo,,jnspection purposes. ��
Signature(Owner/Agent) Date
BUILDING PERMIT PERMIT# . CONTROL#
96413.1.19 3033
DATE WAW VALUATION S'f.lNitidif) LOT. TRACT
JOB SITE
ADDRESS 50-7.555 NiSPF,110 DU
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
iill,ry/j.Utr.rltO CAPASTIRANO 11WIX
CALIMORNIA POOLS & SPAS
50-755 N1SF'irW L7IZ.
4010BOARDWALK YA2
LAQU NTA CA 9'4251
PALKIOFSPRP CA 92260
CMA 3155
USE OF PERMIT
t'u0i, A.fVDOP, SPA
PCWX A.141? SPA ONL Y
P x:"t Abit3/OR SI'A 14,000.04) LS
UVAIMM180 COST OF C10INST RIJ (111' 101N
141000.40
#°#i;illl�f!•!' fs'f.t+: �i.1R�11'1A,1{i�` -
W AN C311:rK t° F..f r 401 -M0439 -31H 19tr: t5
C1'NN4'1'ti.Ur" NC1N, FU 10140-418-M 1153.00
MECHANICAL VVI -• POOL I01 -WO -1721.000 S24.t)0
Fi.d3t:IItiGAf, KY -1 ArKA, 101-01110-420-000 $45(g)
1•' jiMAING"trU)z-- Zh,)cXI ' lili-i?f{fi-41`1-1 (i 327,110
SUR -'rare, CON, IRLTCTION ,WD PLAN CHECK
$3,18.45
LESS PRE -PAID FFI1,' t
�f3.11t?
n
APR 0 5 1996
RECEIPT%-777�•-
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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
POOLS - SPAS
steel
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
Neater 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduk
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: