0005-111 (RPL)LICENSED CONTRACTOR DECLARATION
1 hereby~ affirm under penalty of perjury that iamlicensed under provisions of
Chopte9 (commencing with Section 7000) of Division 3 of the 8uoin000 and
llA/oCoue.anu
mmyt6nm
me|�mnmmmm�*
no66t.
uonoo# uv.o/aaa Exp. Date
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Dateumo/n -
OVxmER'gU|LDERDECLAR4T|ON .
| hereby affirm under penalty o/perjury that |amexempt from the Contractor's
Ucg`veLaw for the ,nVmwinOreason:
( ) |, aoowner o,the property, ormyemployees with wages aotheir sole
compsation, will uuthe work, and the structure ionot intended o,offered for
sale (Sov.7o44. Business mProfessionals Couo).
( )- |, as owner of the property, am exclusively contracting with nm000ed
contractors to onnmmm the project (Goo. 7044. Business & Professionals
Code). ;
( ) | am exempt under Section o&Pc for this m000n________
ooto Signature o,Owner
'
WORKER'S COMPENSATION DECLARATION
`
| hereby affirm undo, penalty of perjury one of the following don|onmiono:
()| have and will maintain ocertificate ofconsent tuself-insure for workers'
oomponuaxioo, as nmviuou for by Section oruo of the Labor Code, for the
performance ovthe work for which this permit ioissued.
( ) | have and will maintain workers' compensation insurance, oorequired Uy
Section 3700 of the Labor.Codo, for the performance of the work for which this
permit is issued. My wnmam' compensation insurance carrier & policy no. are:
Carrier Pvnvywo
STATE FUND � 044'99`00032S
`
(This section need not becompleted nthe permit valuation iofor $1oo.00or|mss).
( ) | certify that inthe performance oxthe work for which this permit ioissued,
| o»an not omp|oyany pemnn inany manner soastobecome ouNoot to the
workers' compensationlaws ofCalifornia, and agree thatif Vuld become
subject to the workers' compensation p isiond I of Section 3700 of the Labor
g_q 3,.,7_u _9
Code, I shaly&rtl#!h comply with those -provisions;
Date: Ir/ 4'Applicant,,,
arn ng: 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
mthe Libor Code, interest and attorney's fees.
|Mpon7AmT Application ishereby made mthe Director o/Building and Safety
fura permit subject to the conditions and mot,inhono set forth on his
application.
1. Each person upon whose behalf this application iomade &, each person ax
whose request and for whose benefit work iuperformed under o,pursuant m
any permit issued oaaresult o,mio,appnuotonagrees to, & o»an, indemnify
ahom harmless the City o,LoQuinta. its officers, agents and employees.
2. Any permit ioouou as result o/this application booumoo null and voiuJ,
work,is not commenced within 1uo''days from date of issuance of such
po,mit, or cessation ofwork for 180 days will subject permit to oonooUouion.
|nortify that | have read this application and state that the above information io
correct. | agree tocomply with all City, and State laws relating mthe building.
oonstmctiun, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purpdses.
BUILDING PERMIT PERMIT#
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER EN61NEER
DUIGN 2000
0. H. POOL (.40.14115TRUCUM
PALMDESERT CA 92211
CATOMRA1. CrrY
CA 92234
(760)328-2681
CDJJ�
69
USE OF PERMIT
P 0 OL AND/OR SPA
PRE -PLASTER INSPECTION, POOL EQUIPMENT ENMU)SURENOT
VALUATION I MOM 141
CONSTRUC-TION FEE 101-000-418-000 9144.00
PLUMBINO FEE POOL 101 -000 -419 -OC* $27.00
SUB -TOTAL C-01487RUC1109 AND PLM CHVCY,
$233.60
IMD PM PAW MW
$01100
TOTAX,FMOMMSDUENOW
$330440
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
i 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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
sf
Bond Beam
Approval to Cover
Equipment Location
Final
Underground Electric
Underground Plbg. Test
Gas Piping
�1
g 17
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover '
Sewer Connection
Encapsulation
.9th
Gas Piping
Gas Test
zoo
Appliances
Final
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)
COMMENTS: