0101-359 (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
Prgfe' ;i Is Code, and my License is in full force and effect.
License # i Lic. Class Exp. Date
614611 f p 12
Date Signature of Contractor "
OWNER-SWiLDER 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:
Carrier Policy No.
Ski:'FLer.At'AMSBURO Ilia, . WC101.17ON-11,0
(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' comp nsation provisions of Section 3700 of the Labor
Code,,, shay forthwith comply�ith.those provlsions.,'7�
Date?, " `� " r Applicant �:''°c~'.�a �~-•. °�" "°`
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject,an employer to criminal penalties and civil fines updo $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. F
IMPORTANT'! Application is hereby made to the Director of Building and Sof .
y.. 'T '
ty
for 'a permit;., subject to the • conditions and restrictions set forth o,; Y
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 above-mentioned property for inspection purposes. p
Signature (Owner/Agent'--"x""`24"-==" , Dater " �r
BUILDING PERMIT PERMT#
DATE VALUATION LOT TRACT
�'T 7 `5t?t8.6�a3
JOB SITE
APN
ADDRESS
.rnP4F°O TAKE SOMM,
79420-TON,
•. _ .
OWNER
CONTRACTOR/DESIGNER/EN (NEER
UMT!L'7 E POOLS & SPAS
`a� •�a f C T,i q��
F10. BOX 1?5;1
USE OF PERMIT
I
PWLAND/OR SPA
'
POOL &.SPA O;t4&,X;•.r3.LA'� MWBA1RR1fiM SHAW, SFS IN PLACE AT PRE
PLASTER MRPIX"TIC;+'KPOOL kTaV M+GLUIX370
Y."ff THIS P.6,11MIT.
Pool, .ANIVORCPA Do W.
PLAN CH1',C"K RE S122,83
C04SYRUCTILTM f'i'r, 101-000,4113-000 $11P.90
MECHANICAL E i/5� 3� wtr?,t/0y0.4p
-POOL T01 -000-421-1000`�(+iLc6.iDnG
t�;E3n1ui��et'4.�. 17~+:yF�.��; y21-(0p}Qg0
1"uI,ncL�:�T .n ICA- 1. jrl!'+7:a •a iy,r41>..r Yj�. F190. °"Mi10U�'YQnlR�60�J41 ip' .i. QYA
PLUMBPAG PER PodL 101 -0004M-000
INC
bB 0r, 2001
Uj-;
i
TOTAL IIYRMff I'VEY DUE NOW
RECEIPT
DATE 2 g
BY' `
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set- acks
MECHANICAL APPROVALS
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
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
G O
Underground Plbg. Test
Final I I
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
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)
Final
COMMENTS:
SloV(.(01
1
5%
—
CITY C F LA 0
-
BUILDING & SAFE P. ( DEPT
APRRI. �VKZ)
FOR C(iNST R%','CI-ION
DATE 1 By
A RE -INS I 'ECTION FEE OF $30
WILL BE CH MED IF THE APPROVED
PLANS AN JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTIO
N I
EXCEPTIONS!
TIONS.
12r
L
12W, Mm 52
a, Ar 'Ir -W Tpwlw rw% V-4 Lic. # 61A611
off ■ Insured
.LVAL JL Is i AL JLW.A-d
Mike Mcintrye
CONSTRUCTION SPECIALIST Owner
P.O. Box 1791 • Lo Quinto, CA 92253
thillRe: iso 360 -3585 - Fax: Iso 360-3435