0006-109 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affid.-n under penalty of perjury that I am licensed under provisions of
Chapter 9. (�� •� nmencing with Section 7000) of Division 3 of the Business and
ProfessionalsJode;"Ad my License is in, full force and effect.
License # Lic. Class Exp: Date
656128 C53 101 1/2(
.�4". ' x -' n,:�, . .,.v,,..<,s+.-- e,�.,+��;T._,;�A� w+.+riw••et 7h:�i..
Date L 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:
( ) 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). -
O 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 ST.A`TE Policy No. 046-00-0006161300
(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' compensationprovisions of.Section 3700 of the Labor
Code, I shall forthwith comply, with those provisions.,
Date _ ___ ._ _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 a's 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 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 aboveymentionedpLoperty forinspection purposes —A—,
Signature (Owner/Agent) �7 - "• f,r•� ,_ Date -?..
BUILDING PERMIT PERMIT#
�`�-J.
ATE
VALUATION LOT , TRACT
$1>3
JOB SITE
APN
ADDRESS 79-970 TAJ1G.E .O
_ —
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RRY'SOUTHAM
CALIF'OR14TA POOLS & SPAS
19-870 TANGELO
74-723 JONI DRIVE. 0.
LA QUWA CA 92253
PALM DESERT CA 92260
C/60)340-9000 MR, 355
USE OF PERMIT
POOL, ANDIOR VA
POOL & SPA ONLY • ALAR'UNIBAR.• IM SHALL BLY IN PLACE, AT
PRrv,PLAsTrim 1?4SPF;a I014. BLOCK WALLFOR EQUIPMENT ENCLOSUalt
IS NOT INCLUDZU.IN THIS 1aL''RMIT. BfiQ A14316221,59-1995
VALUAT1014 10,000,00 L5
ESTl(!/l.AIED COSI' OTr' (;0149M(JC f70N
�f3,tI11!?.Oti
PESY1 rYKE WhOAii;' Y
P4AW C1iL?t.K ''F, 101.000-439-318 SUMS
COMSTRUCT)ON FEE 101-0004419-000 $.189.00
� x
MECHANICAL. irRkl; -- POOL 101-000-421-000 $24.00
LPI,.L+ TRJCAL FEP -. POOL 101-000-420-000 $45:00
PLUMBINOIE9-• POOL 101-000-419-000 MOO
t,;r ` l l
- LUA9IllPd019 - -- — 101-=04Q-419�OW -- — `-118.00
3
s
A
SUB -TOTAL CONiiit'd.TC°T`IOM AND PLAN C•`'IIiM.
IMS PRE -PAID I:M .
$0.00
TOTAL i�.�I?Mf-r MIN DUENOW
:41-w
Y t
RECEIPT
DATE
I BY I1
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION.
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
I, Backs
Underground Ducts
FTrm's & Footings
Ducts
Slab Grade
Return Air
Steil
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
7—,,"0 -
Set Backs
Electric Bond
- Id
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
Pool Cover
Sewer Connection
Encapsulation
— U
Gas Piping
Gas Test
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: