0007-226 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 70`n) of Division 3 of the Business and
Professionals Code, and my License is:,r ,Il;forcX"* and effect.
License 4 L c: ClExp. Date
C53Date 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).
( ) 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 STATE FUND Policy No. 1344032-00
(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 Califmi ,and gree that if I should become
subject o the vor ers' compensatie provisions of Section' 3700 of the Labor
Codeq rf�all fort' ith comply wit t -se'pr`ovisions.
Date: � Applicant �� I
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 hot commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
�r BUILDING PERMIT PERMIT#
DATE VALUATION LOT '2� TRACT
�i�,Cf€}4i.t3U
JOB SITE APN
ADDRESS 78-572 W"G R0(X TURN
OWNER CONTRACTOR/DESIGNER/EN &NEER
DON A MON MANTs , F'AMMY POOLS CO14.Tr. tTTCTi0iT
78.571 TALYJNGROC&"i' _RN 53300AVF,14.tiDARA El
1:,AQCIINTA. CA 92253 LAQ TWTA CA 92253
Q60>564-3655 CBU 2893
USE OF PERMIT
POOL ANDIOR SPA,
s
POOL & SPA iJN1. Y-AL.l4 RMSIBARRIM SHALL BE 1N PLACE AT
PRE-PLAWR WSPECTTOK
VALUATION 13,000.00 La
XgrHVTAI'F .i COST OF C0.W0fRUC 1T0.N
180 0.00
F .t
PLAN MIECK TMEK
101.000.439-318
$132.04
CONSTRUCT10N Wit
101-floo4l8.0o0
$199.00
MECHANICAL FEF .- POOL
101-000,421.,q,)p
$200
ZL1:.0 fPUCAL PEE -- POOL.
101-000-420-000,.-N
$45.00
PLUMBING PER' - POOL
101-000419-000.6
$Z1.00
SLM-TO AL CONKRUCUON' AM P T_M' Cit 9CX
LXZS PRE-PATD TWO
I certify that I have read this application and state that the above information is
correct. I agree to comply with ail City, -and State laws relating to theuilding
construction, and hereby a'tl,�orlile—representatives of this City to ent�r upbn
the above-mentioned property, f r Inspection purposes.
� � RECEIPT + DATE
Signature (Owner/Agent) �'l� Date _
'%' fAL IPM.NL r SES DUE�TO�N
';
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
Fire *,ce T.O.
Fans & Controls
Pal., )Nall Insulation
Condensate Lines
Party Wall Firewall
Exteg?r Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS
_
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground P[bg. Test
Gas Piping
_rv•
PLUMBING APPROVALS
Gas Test
Electric Final
D
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
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:
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