0006-222 (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
Nrore991011.119 L C18, tthd my Llcehse IS In fuji force and effect.
License # Lic. Class `' Exp. Date
6561: 28 C53 1 f?I3112C
j7Date ' ' 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.
( ) 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:
Carver STATE MD Policy No. 046-00-0006163-00
(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
su Iect to the workers' compensation provisions of Section 3700 of the Labor
K I shall forthwith comply with
,.those provisions.
.,
ate:_ :71 --Applicant—
Warning:
-Applicant 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 186 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
construction, and hereby authorize representatives of this City to enter upon
thabove-mentioned property for inspection purposes.
r
Signature (Owner/Agent)- % raw -- Date` D
BUILDING .PERMIT . PERMIT#
DATE VALUATION C LOT OW -22-2 TRACT
JOB SITE
APN
ADDRESS V -SW TANGELO
OWNER
CONTRACTOR/ DESIGNER / EN (NEER
1%06mra lli cm.
CALWORMLA POOLS & SPAS
79.860 TA14G''-�C� -
74.725 JONI1Y'l2 #A.
LA QUINTA CA 92253
PALM DESEP.`i C.A. 92260
(760)340.9000 C'2 LO 355
USE OF PERMIT
POOL AM/oR SPA.
/
POOL eft SPA (WATER "..,41URk) ONLY- ALARMSIBARRIZIZ3 SHALL, BE TN
PLACE AT PR&PLASTER I OWCTION, BLOCK WALL FOR POOL
EQUIPMENT Z14CLOStIRIp 15 NOT INCLUDED IN 1'HIS PERMIT
VALIJA.TION 21,300,00 La
MS1M%A1XD COST OF CONS`.[RUCnON
22,3=OD
PERWf EVE SPRY
i�I�AN CnC•1e. M, F 101-000-439-318 $146.21
CONSTRUCTION .IE 101-000.418'_000 W5.60
� •;
MECHANICAL FEE.— POOL 101 r0(*421.000 424,00
R --LF. CTRICAL FEE - POOL, 141.000-420-000 $45.00
r
PLUMBYHO i7TtE - POOL 101.000-419.000 $27.00
µ-'-
pr
MM-TC.AAL 0,OHf TIR'UCTi09 AWD PLAN Cf1ECR
$469.25
1,9833 PRE -PAID FEES
$0.00
!; TUYALMIMUr!r�'I+ESDUE NOW
I
W725
• r
RECEIPT
DATE/BY
Ji` /
DATE FINALED
INSPECTOR
/i
INSPECTION RECORD
OPERATION
DATE
I 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
_O - e'd
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
G: QD G
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
C'
l/
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures-
MaininService
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)