0402-107 (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 Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date • t ' t ` ` Signature of Contractor -
2`r
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 "'t'r"'r'` '�-_ Signature of Owner--*�---
f N
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the/,following declarations:
r ( ) 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.
STATE x IMI) 1615074-0;1
(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
1; I shall forthwith comply with those provisions.
'"t'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 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 above-mentioned property for inspection purposes.
,1 -,,Signature (Owner/Agent). Date
It/
BUILDING PERMIT PERMIT#
DATE VALUATION LOT-`d(j'y TRACT '
JOB SITE
APN
ADDRESS
55 -SM TTfa'c.NWIMY wily
-
OWNER _.._
CONTRACTOR / DESIGNER / EN 1NEER
DAO 11M..3i::&U-N1'S
0:kC1'uso POOL, PLI t MING, INC
P.O. BOX 1286
6 67 KCTr=MB RD,
WLJNS1°'.i Bl:''ACH CA 90742
PALM SI>ftlNGS CA 92264
(760)327-759 • C'M0 816
USE OF PERMIT
POOL AMOR SPA
POaJ1SPA. AGARIAMAPURUERS SHALL 0213uPLACIT.ATPRE-PLASTL,
t1 SPEC`S ION. ^u<<,,UIPMEWT ENCLOf3t31tL NOT ]INCLUDED
POOL AND/`,R SPA A000.00 JU
Ft'rM'MA.'TED COST OF COI S;iRTJ ON
iib fi00.t313
PLA14 C.grZ'i SEE 101-000.43,9.338 M4,93
CONST .Rucr1 [Oia tom; 101-000-4 i S-000 $284.30
MECHANICAL FEE -- PO7L 101.000-421.000 $24.00
FLEC` RICAL FEE - POOL 101-000-420-000 $45.00
PLUMBING YEE _- P00L 101-:100.419-000 �EY.40
-
D Q D 0
FEB 12 1004
CITY OF LA QUINTA
FINANCE DEPT.
SUB-'t"OTA:G t HM-TYC'11014 AM P:tIW CMCJK
i$365.43
.1M341RE-P .n_F9
Roti
TOTAL IyIS1C'a.t *Tff 1TELPS DUE NOW
SM5A5
Y.
RECEIPT
DATE J
BY
f
DATE FI LED
�
INSPECTOR .
�) • l ,} f !
Z�i Q
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
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test Y
Final
_1A
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 77 a
Gas Piping
Gas Test
Appliances
Final Z
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior. Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)