0201-181 (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 # Lic. Class Exp. Date
Date Signature of ContractorI' r i-_ e r y,+�• �✓
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 S"PATS C'0111PENSATI, Policy No. 046-02 0006160
(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 the e proyisions�
Date: Applicant— �✓1w T.
Warning: Failure to secure Workers' Compensation coverage is unlawful and i
shall subject an employer to criminal penalties and civil fines up to $100,000, in
{ addition to the cost of compensation, damages as provided°for in Section 3706
of the Labor Code, interest and attorney's fees. ; ..
IMPORTANT Application is hereby made to the Director of Building and Safety)
for a permit subject to the conditions and restrictions set forth on V,
application. S u d
1. Each person upon whose behalf this application is made & each persomW .
whose request and for whose benefit work is performed under or pursuan"ito
any permit issued as a result of this applicaton agrees to, & shall, indemnify
&.hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and-Vid if—
work is not commenced within 180 days from date of issuance ofµsuch
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propert�y,jor inspection purposes. f
Signature (Owner/Agent) Ae7�l P lr � O Dates
• BUILDING PERMIT PERMIT//
(( ;
I,'M / Q''
DATE VALUATION LOT TRACT
WAWA* dpi
JOB SITE C
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
(T?1WMC 1110MM
CAUt' Edi i h POOLS & SPAS :P MAN C01
a 2180WMEILO NY C1T a"r., SUITE 150
'X4'725 JOIN! DIUVE,, SUTAV Ah
L"'CtTtONA. C.A, 91720
1 hM L1HaZRT Cdr 92260
(76q)340-9000 C)SU Dov' S
USE OF PERMIT
SPOOL fiNDWOR SPP
POO e'SPA/0330 A235i 221.58,1990. ALARYdfMr$I RIP S SHALL BE IN
F'LAVE AT PIM-PIAISTER iMMMON, POOL EQU1PMRNT MMOSlrRE
NOT INCI.t>!M3.
POOL MMOIv SPA, GC�,e00 ZI01 ai
1:9111111MED COST OF C".+fY MVIC.110K
�TA,`50dX.t�b
PLAN CHEM FI~L 101m4DM4.39.318 SM40
CONSTRUCTION vele, $216.00
KEOF4 ANIC A!,, FEE, - P001, ' " 101 •-100.421 d0W 'SX00
1a,LrOTPJCAL I*B a- POOL 101-000-420.000 $41011)
PLUMBING PEI 9- POOL 101.009.419-000 `27,0
JAN 3 12002 "�
eA`3AIIM +'..i1CM..fSONMD PLA N G�f�'CKM
t}`4521.40
—,.•••-•-^••••--:; . y���1`IVAL .¢
66 �{•�TT� pa�y��p�.�+ �K �g�Y��j �{q/•y�y
RMT .I . ��ea' b .l.r ll7.Gr. �'f!1"y f
�ja�¢ �•7�
i�?452.40
RECEIPT
DATEj� i
l
BY!
DA
SP TOR
o
re
rA
J).
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
I Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
, Compressor
Insulation
i Vents
Fireplace P.L.
f Grills
Fireplace T.O.
i Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
1
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 Test
Electric Final
Waste Lines
Heater Final
Water Piping
j Plumbing Final
Plumbing Top Out
1 Equipment Enclosure
Shower Pans
1 O.K. for Finish Plaster
Sewer Lateral
[ Pool Cover
Sewer Connection
_
' Encapsulation
Gas Piping
1
Gas Test
Appliances
i Final
/� 6 y
i COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
i
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)