0106-111 (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
V. Professionals Code, and my License is in full force,and effect.
License # Lia Class Exp. Date
536236 fila
Z-') I. Signature of Contractor
--
OWNER -BUILDER
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: �i�
( ) 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
Pfction 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 EXEMPTPolicy No.
(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 shouldl become
subject to -the workers' compensation\provisiorrs of Section 3700 df the Labor
Code trf shall forthwith compljY, vk'Ith those�vis'lonsr.
�: +� A Applicant ate. E:'
Warning: Failure to secure Workers"Comppsation coverage is unlawful and
shall subject an employer to criminal penaltiel and civil fines up to $100,000, in
addition to the cost of compensation-, amages as provided for in Section 3706
of the.Labor Code, interest and. attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his,
application. &I
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Ouinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date. of issuance cf such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply' With,all City, and State laws relating to the building
construction, and hereby authorize representatives of t?.!City to enter upon
the above;mentionedfproperty for inspection purposes. r
Signature (Owner/Age tN. ��� y `�i+ �FA Date(. -- e �' -
/ t
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ? �r[��,_$ TRACT
JOB SITE/ v L
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
Mr C't.FS'z=
S)UNIZISE. POOLS
43-065 `?°A17RUS (Z
82x762 CHARI ` ONAVE
U! Cmr—N l ik i',.A 9T7-53
W110 CA M_'z a '
k-7609)275.6403 CMN 1664
USE OF PERMIT
PCAi sa ANDIOR WA
INSP '€' UH, POOL i?Q€JIi?MEWT MCS.,OSURE NOT MCfuUt1 D
POO ANVOR SPA 1A
ESTMA. ' � . COW CDS" Cf5MMUMON
PE N
PLAN G"-1i.BCK M 101-000-43,9-31'4 5111.15
M4S a RUCTION FEE 101 -000-41 S -WO $171.00
>��q.&�t~y£�p.�p.�:1 ICA.Lq -• € OOL 1101.000.412:1 -♦000 1200
11/+�EZ
V, M:a1; JX I A�n.L P�sti , POOL ! M 1 —Q0C)- 420 (:)V $40,00
PIADMKIAO FE ,.. POOL 101.000.419.000 $27.00
&,M-4OTAL CON -5Y UCTRON :ARD P.LA9 C:HW-K
�'i X 15
I.�`€ME TIMI -PMD MIS
$0.00
RIMFEES DUE NOW
1's�1Is
I
(.J J U N2 2 2001 i J
1
RECEIPT
III
bMLAU IN
i1NANCE
ABY r'
%
DATE FINALED
INSPECTOR
DEPT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
1k 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
I 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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
U lity 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)
Final
COMMENTS: