0004-278 (RPL)LICENSED CONTRACTOR DECLARATION
2 I hereby affirm under penalty of perjury that I am licensed under provisions of
k.Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and:eecLicense # ` Lic. Class f . Exp. Date
$8996, C53 DatSignature of Contractor +
OWNER -BUILDER DECLARATION
I hereby affirm under penalty 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 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 STATE FUND 4i Policy No. 1344032.00
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performancelof the rk-,f'or which this permit is issued,
I shall not employ any person in any nner so as to become subject to the
workers' compensation laws of C lifornia, and agree that if I should become
b,ectA t e. workers' com e}}iorl. provisions of Section 3700 of the Labor
de 11 s l fortfSwith complyC4vith h
Pate
se rro inions.
: Applicant
Warning: Failure to secure Workers' kompensation coverage is unlawful and
shall subject an employer to criminal pealties and civil fines up to $100,000, in
addition to the cost of compensation, daV'ages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his .
application. :•
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply vt.ith all City, and State laws relating to the building
construction, and hereby auhorize representatives of this City to a to upon
th above-mentioned propert f'.r irisp`ection purposes.
Signaturee (Owner/Agent) `\` Date U,
N -00 BUILDING PERMIT PERMIT#
OQ41-278 .
DATE VALUATION s1s,ow.00 LOT TRACT
JOB SITE
ADDRESS 79�3M IgT=o Dp
APN
-
OWNER
CONTRACTOR/DESIGNER/EN INEER
NIR- & MR8. CEREG SCOn
FAMN LY POOLS CON'SM CITON
79.302 NUEVO
533i2A1�9%00 AVE141DAZ,
LA QUIIDTrA CA 92233
L & QUDUA
CA
92253
('760)5564-365'
C:BIJ$
2893
USE OF PERMIT
POOL ANWOR SPA
V'ALUA.TION LS
XMW" COST Off' CONgrRU'C'X'IO:I'R
• �.da ;�
��yy �g� 77����y 7y��� g���yp
ArES�.Cil.4 � A dt E &UZY.l.1.VEA R i
PLAN CHE4K YU 101.000.439.318 $103,30
CONSTRUCTION FEE: 101-0100-418-000 $1Go.GO
r"
?AECHA LAICAL FEE -= POOL 101-000-421-000 S24."
la;, ECTRICAL FEE — POOL 101-000-420-000 $45.00
P1LUMBWO FEE -- POOL 101.000.419.000 $27.00
.77
C-1 i
SUB 401AL COW= UCTtON AND PLAkf CB MWX
$363.30
UM PRE -FAM FM
$0.00
'X'Of'AL YMW. M FEES DUE NOW
$30130
J
RECEIPT
DATE
BY� /'A
DATE FINALED
INSPECTOR
c"•
INSPECTION RECORD
14
OPERATION
DATEINSPECTOR
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Bond Beam
Main Drain
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
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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: