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LICENSED CONTRACTOR DECLARATION BUILDING
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 DATE / VALUATION
Professionals Code, and my License is in full-force
e and leffect. /
License # a Cl
Liass � ' Exp. Date F
713 3:x(,21
Date-ySig�nature of Contractor
OWNER -BUILDER DE
I hereby affirm under penalty of perjury that I1�,.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).
( ) 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 Policy No.
(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' compensationiprov s ons of Section 3700 of the Labor
Code,hall fo, hwith comply with thoste provisions.
Date: is ! ! ! ( Applicant Y, E.��/✓
Warning: Failure"to "s`ecur? Worke ss)CoPpenssation`coverage is unlawful and
shall subject an employer to criminaljoenalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of, sucwr
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby rauthorize✓representatives of this City to enter upon
the above-mentioned property for Inspection purposes.
Signature (Owner/Agent) !.'� 1� Date
JOB SITE
ADDRESS
OWNER
PERMITPERMIT#
LOT f� TRACT
APN
CONTRACTOR/DESIGNER/ENGINEER
'%WDU1014 MUDAMOCIA112, UC iR0111M fiJIN iiSTORT4 POOL Ct?1 ED. -K
1A.1505 INVENUE 52 11485ZLM4N0NkAr,'17,#3i
%.rR+. Q7i IINTA CA 9225 3 I3ia7M.B)Ii..S R31 CA 9221.1
(76E0)568.4993 CIW$ 51.15
USE OF PERMIT
POOL •. D JOR IWA
'tyf_71.AS?'&.,AJ_.0.Fi+iSt'HA1Z.RZ1 F,1'Z3 SW -44, VIP, IN PLACE AT PR14-FIA s'i'1aA
RNSPY,C TION. POO), OQUIPMINT ENC'tet),'SURE NOT INC1.,i1D913
POOL AMOR SPA
11!080100 i's
;@i;1�,i'I1 IRI31GrOM' OF i,'.'t2W).RUMIf;)N
FLAH CIHEA-ix lam,
101.000.439-.318
;ONS q YRIC3,1014 PKIN
101.000-4 7 €t -t=
MECHANICAL FRE "' S'0011
101-000-421-000
Xl.WT.WCA1.. 10F9 R,. f"CX 3,
101 _000.420-wo
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::f}1.'iFMBIA 0, F -Se a,• POOL
101 - 00.419-f. DD
00
1111M PRE -PAID. IMM
DYE; .NO
AUG 2 t 2nn1 FA. ',
Quire,;..
$M I'Ski
$0.00
M1.80
RECEIPT I DA E B I D fE�J A DQ�IANSPEC�
�l
I<�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum.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
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
Final
A -Anz
Electric
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
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
,
Exterior Receptacles
l
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)