0208-031 (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'i Lic. Class -w , „ .'". .Exp:--Date-,v--
Date
.Exp:••Date-,v --Date �! ' Signature of Contractor—
OWNER-BUILDER
ontractor 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. fof 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.
\(1) 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 FjTATE I?'i NI> -Policy No. W-01-0019,834
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the workMor which this permit is issued,
I shall no` employ any person in any manner sofas to become subject to the
workers' compensation laws of California, and agree that if I should, become
subject to thworkers' compensation provisions of Section 3700 of,the Labor
e
Code, I shall`forthwith comply with those provisions.
i`Date: i '
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 antid state'that the above information is
correct. I agree to comply with all`City, and +State laws relating to the building
construction, and hereby aLthorize representatives of this City to enter up ri
the above-mentioned propertyfor inspection purposes.
Signature (Owner/Agent` - '�- Date
ENJILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
:S[,lit� 143
JOB SITE I
APN
ADDRESS 47' N" „ rMBES
»
OWNER
CONTRACTOR DESIGNER INFER
CAAIMAAY" u • COMPAWY
HAT.lli)W dba VAC&TION PCW0LS
17480Z Mkl i ii ' #; l (f6
9522 DON SON RD.
TURM CA, 92780
LUMM i3'ALIAM CK 92.`136
""(760)20-6045 MIX
USE OF PERMIT
POOLAR11VOR OPA
POC.i IASM.A, ,14Lt, FU.01BARRI. ERS SHALL 09 IN PLACE P''RICA TO
PTtE.IjLA.�'s�L��i 1�SPCsf�'TiQ�
POOL "WOR SPA M060.00 LZ
PVI&ffr V, KE 91MOd"Y
Pli.411 CHEr9 MR, 101.003.439.318
COWSE'RZICT11 '(a IE -E 101-000-418-000 3162.00
M. F-C-i3.ANIC.AL FRE -- POOL 101-000-d21 -000 $24.00
ELWTRICA:(, FEE - FOOT. 101-000-4-20-000 $45.00
PLT 13 is 7'r,3iACI "A , -- POOL 103.000419.000
x
o LESIS PXFZ�PAID FEM
2.0.00
:1?7 °1iUT MIS DUO, NOW
930.30
C
F1 pNCEDEP'LA
RECEIPT
DATE ^
BY r
DATE FI LED
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
p
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
5
Final
Gas Piping
J
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Finale
3
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)