0006-110 (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 Cede--an4 ny_License is in full torce and effect.
License # Lic. Class Exp. Date
fs61.28 C53, 1013. I L_-
. y„N'
Date 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). -
(
ode):( ) 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 aintain 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 workfior 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:
Carrier3T'.ATE 1;UND Policy No 0@6:-00-OOOtS1tS�•O0
(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' compensation provisions" 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 as provided for -in Section 3706
of the Labor Code, interest and attorney's fees. .
IMPORTANT Application is hereby made to.the Director ofBuilding 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 personat
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.
r.
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 above-mentioned property for inspection purposes.
Signature (Owner/Agent) �"`,- L� ""' = '--.-...... ate—.,--" ;
BUILDING PERMIT PERMIT#
_110
DATE ( �,VALUATION LOT TRACT
JOB SITE
ADDRESS 79-91.0 TA1.gG ..O
APN
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
a.9OUGIAS PLECIA
CALTFORNLk POOLS & SPAS
79=910 TANG04 .0
74.725 joya Dm4 m
LA QUINTS CA 922S3
PALM DESSERT CA 92260
V60)3401--9000 CRL4 355
USE OF PERMIT
POOL ANDA.YR UPA
POOL & SPA ONLY • Al.ftR}tifl;,"1aARRIERS SMALL BE IN PLAMI AT
PIS&PLASTER 049PEC;TiON, BLOCK WALL FOR EQUIPMENT ENCLOSURE
IS NOT INCLUDED) IN THIS PRERM1T. BBQ ANSI 0 221.53.1993
FOOL AWD/OR SPA LS
E ►£ �'. 'I'= COSI' OF Ct7NS"lCRUC:I OW
19.700,00 .
1' EMM FM SUN04ARY
PLAN CHECK FU 101.000-439.316 $134,55
CONSTRUCTION FM 101-000.418-000 $20'%OO
MECH.A141CAL FER -- POOL 1012000-421.000 $24.00
-,ELECTRICAL VER,, . POOL. 101-000-4.20-060 03.00
PLUMBINO FES: -- POOL ` 101.000.419-000 $27.00
PLUMBING} FU 101-000-419-000 $1€1.00
,y
�-1
SUB-TOTAI:, CONMUCTION 114JD PLAW CHEQb
55.55
1"S PIKE -PAID MYSI
$0.00
TO7_rALPY.RWff.FXES DUE NOW
$455-5.5
RECEIPT
DATE
BY`-•.DATEFINALED
INSPECTOR
s .
1j
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
Roo,_i +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
steel
/o -
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
_ za- 42E
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)