0801-151 (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 # f Lic. Class Exp. Date
Date 5 -. a D ' Signature of Contractor � 1 o fa
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I 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 •Rsyrrs CoMp1�JS 'i'I Policy No. 046-U2 4tk2fSl.$f!
(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 shall forthwith comply with those proyisions
Date: it f1 40• Applicant— /'� Af
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,doij,Ji'
addition to the cost of compensation, damages as provided for in Section137U6
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and ! fet
foe a permit subject to the conditions afid restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each pers -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 s
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 , urposes.
Signature (Owner/Agent) �1 Date
G`�1 :C Ho. we, 3
21280 V11rAIM.L w =04 in. Urkv, 15
COKON'AC.A. 91720
USE OF PERMIT
POOH.. MVC R iPai
C AL ¢ ORITU POOTA �l�:.%1,'t 8 (TOPMAN
14125 JONI DRM , Mr.C1a. #A
a IA1,11.t ; ESEMr 'CA 92260
(760)340-,9000 CM4 00355
12001.>►SPA®RS STUD, BOO (s2`,SI ry,t %4995) ALARMS,
RARMEU S) AJ. ,L BE IN RACKAT P001,•
EQUIPMENT mc%osunNar INt;Y.taDED.
Pool, i NIXOR. SPA
1:GV000100 1101
ESJf.N AIED COST OF C0NYMUC ION
BUILDING PERMIT
PERMIT#
DATE
VALUATION/�1'q� LOT
T_ ACT
R
CONS1`R'i3C. ION ME
101.0001 418.000
MAW
M1WTHANIC.fi;<1, YKE r POOL
101-000-421-000
JOB SITE
FI E'<w,:TFUC,43. PRE a., POOL
101.000.420-000
APN
P;U1XM)"sPA* 71 , -- POOL
ADDRESS
1 1.469 R.PANISM IDAY
„
OWNER
CONTRACTOR/DESIGNER/EN INFER
G`�1 :C Ho. we, 3
21280 V11rAIM.L w =04 in. Urkv, 15
COKON'AC.A. 91720
USE OF PERMIT
POOH.. MVC R iPai
C AL ¢ ORITU POOTA �l�:.%1,'t 8 (TOPMAN
14125 JONI DRM , Mr.C1a. #A
a IA1,11.t ; ESEMr 'CA 92260
(760)340-,9000 CM4 00355
12001.>►SPA®RS STUD, BOO (s2`,SI ry,t %4995) ALARMS,
RARMEU S) AJ. ,L BE IN RACKAT P001,•
EQUIPMENT mc%osunNar INt;Y.taDED.
Pool, i NIXOR. SPA
1:GV000100 1101
ESJf.N AIED COST OF C0NYMUC ION
T120MMM Iz3i' ID"RY
PLAN MWX FEE
I01-000.439 31&
CONS1`R'i3C. ION ME
101.0001 418.000
MAW
M1WTHANIC.fi;<1, YKE r POOL
101-000-421-000
S20D
FI E'<w,:TFUC,43. PRE a., POOL
101.000.420-000
Y4.5.W
P;U1XM)"sPA* 71 , -- POOL
101_00 1.9.000
MOO
ktl I .
Ail 31 2002
IITY0FLAGU(R"'A
LESS MR-P.41b P 03;
YE.WXY ME N DUE NOW
RECEIPT ` I DATE 7 J I BY
• I.Wy�6li6f�
,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.
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
Set Backs
steel
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
/aste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipmen@ Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
FinalCOMMENTS:
_
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
.Underground Conduit
Rough Wiring
Low Vottage Wiring
`_Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)