0007-068 (CP)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
.—Fv.6fession6ls Code, and my Li46 is,irfull force and effect.
License # Lic. Class Exp.'Date
656128 C53 70/31/2(
Date ✓^ % Signature of Contractor=>---�-
s
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:
Carver STATE KMD Policy No. 046-00-000616$-00
(This.section need not be completed if the permit valuation is for $100.00 or less).
(Y) 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 provisions.
Date: ^% / , 00 Applicant—
Warning:
pplicant 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 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) ' %� "�-�--1---- - -Date
/9'I
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BUILDING PERMIT PERMIT#
DATE VALUATION OW? -M TRACT
$4,8W.00$4,8W.00LOT 33
JOB SITE
APN
ADDRESS CaIXF MRIT
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CEWfCURY CROWa L 0rA0oGMrM2
CALIFORNIA POOLS & SPAS
1535 30, `D" UIREELIMT1, 0200
74-725 JOM P,10AM 4A
SAN BRIMARDINO CA 92406
PALM DESERT CA 92260.
(760)340.9000 CBU 355
USE OF PERMIT
FOOL ANDIOR SPA
SPA ONLY'•ALARXiSlE3"RIERS SHALL BE M PL&CZ ATPRE PLASTER
INSPECTIOAPOOL EQUIPKIEWT-MI IX)t' i!RF IS NOT INCLUDED !N THIS
PERMIT
POOL ANDIOR Z'PA 050.00 L3
ESITMA,1.110 COST OF CONSTRUC1110H
050.00
PLAN CtIECK FEE 101.000.439-318 $4b,O0
x,
�7
CONSTRUCTION FEE 101-000-418-0100 $72,00
1dIEC�IANICAG PLS, •< POOL 1 Ol •QU0.4�1 T.(?OU $24.00
_
W,CTR;CAL ME -• POOL 101-000.420-666 $45.00
PL11Idi33IAIC+ FEE - POOL 141 c44Ua419m000 $x7,00
BUB -TO'. AL CONSTi7TJC" ON AND PLAN C MCK
$214.80
LE33 PRE -PAA? MS
$0.00
'fur" I' bI w MIX DVE NOW
$2,14AW
l j
RECEIPT
DATE
BYE^ F
DATE FINALED
INSPECTOR
_
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INSPECTION RECORD
Lh, OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
Parry 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
000,
Final
Underground Plbg. Test
Gas Piping
_ _
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PLUMBING APPROVALS
Gas Test
Electric Final
1.010,
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
1,06
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:
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FROM CALIFORNIA POOLS AND SPAS PHONE NO. 7603465407 Jul. 12-2000-0B:00AM,P3
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