0104-241 (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
Dat Signature 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:
( ) 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.
'N(j0 1 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.
-STATE YOM) , 046006169 -OD
(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-.-
subjgct to the workers' compensation provisions of Section 3700 of the Labor
C e, I shall forthwith comply with thosrp ovisions.
tate: 9 Applicant ' ��
��
Warning: Failure to secure Workers' Compensatiort coverage is unl u nd
shall subject an employer to. criminal penalties and civil fines up to $1 in
addition to the cost of compensation, damages as provided for in Se i 7 6
of the Labor Code, interest and attorney's fees.,
IMPORTANT Application is hereby made to the Director of Building a d Saf ty
for a permit subject to, .the conditions and restrictions set fort on Ilis
application.
1. Each person upon whose behalf this application is made & each erson at
whose request and for whose benefit work is performed under or p
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
constryction, and hereby authorize representatives of this City to enter upon
thee4bove-mentioned pro:1,
for ins
ection purpo
Signature (Owner/Agent),~ �� / Date
_
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0104--1241. TRACT
JOB SITE
APN
ADDRESS
. TA,ISIGi:.!?'nIN00-:b)
7155-01M•4
OWNER
CONTRACTOR/DESIGNER/EN INEER
(SIN U.,R.Y MZ01M , Z. MKORMS
CALWORMA POOL S & S Ais
1$35 50, -D- M±°fCF?IfZ w17, 02.0 1
74-77, JQN(D. MNE, 0A
81W K:1< MF.NNO i wk 97A08
PALM DEUMT CA 92260
(760.)340-9000 CS -14 # 5386
USE OF PERMIT
P001, AND/OR SPA
PCir; USPA ONLY. ALA�ZYISAPFARP�. EPS SHALL, BEEN PLACE AT
TRx.4S'6yE.cR7ST .R,.'I BRICTIION, F100L tuQUIt"�W1:,' T 18 140T rArLr.f1 E'D P1, ,
THIS 3.'K1T',Y1PT.
M3;,+ANd3/OR PA 2 ; f161. fi 1.4910
3
PRRWUVIM1 SUMMARY
PLAN C'HWX TrRE 1012>ti�ii��35��31�� S1�i��lfl
G;ONSTRU'CTIGN M. 101,.000-418-000 PICK
IISCHANICAL YEF, -- P001, 101.000-421.000 $2/9A
XLW.,TP:'€V,,AL ITZ a POOL $43.00
)PLUNIFInN143 FRE POOL 101-000,419-:000
P R 2 0 2001.
CITY OF LA OUINTA
FINANCE DEPT
AL CONWMIYCTIO14 AND AM w',
X452.40
• . :ES��a+T Y?"sZ2�n:&'.P�1T,3 F�I?'.� •
�C�.E3t�
'3.WAL P=MT MS ,DIM ROW
$452AO
P
-
r
RECEIPT
DATEBY
/ /
/ /s
DATE FINALED
INSPECTOR
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel _%
_
�I D�
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
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)