0004-096 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby m unser penalty of perjury that I am licensed under provisions of
Chapter commencing with Section 7000) of Division 3 of the Business and
Pf6te§Signals_ lode, and ffiy License it in full force arh effect.
License # Lic. Class €zp. Date
89 _33 I /.10/2r
Date �` Signature of Contractor{
OWNER-BUILDER DECLIRATION
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 aldation is for $100.00 or less).
() I certify that in the performance of the ork for which this permit is issued,
I shall not employ any person in any nner so as to become subject to the
workers' compensation laws of Calif mia, and agree that if I should become
subject to the f orkers' com e�tio provisions of Section 3700 of the Labor
Code, I II f rthw th co plym `with tho�setprovisions.
Date: Applicant �V
Warning Fail re to secure Workds' Compensation coverage is unlawful and
shall subject an employer to criminal Renaltiet 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 Quints, 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 appli ration and state that the above information is
correct. I agree to comply with a I City,and State laws relating to th) bui ding
construction, and hereby authori e,,tepresentatives of this City toe Iter p n
the above-mentioned propq& o i speotion purposes.
Signature (Owner/Agent) �` 7'a ' Date1
l
UILDING
PERMIT' PERMT#
DATE VALUATION
j`
Iffi
LOT ^ TRACT
$t i3OiC w
JOB SITE
APN
ADDRESS 45-155 S,UVElI M, Y COUM
- -
OWNER \,
CONTRACTOR / DESIGNER / ENGINEER
-a
`
Arw. MODDE
F'AMU Y POOLS C014MUCTION-
i -
4.5-135 3UNBEERRY COT -RW
53300 AVMMARAMT–I Z
Lia Qi.1WfA.
CA 9^4233
TSA QUWTA CA.
92253'
(760)564.3659 Mi L#'2893 1
4
`•tif. 't
USE OF PERMIT
POOL A.NDIOR SPP.
.POOL &SPA ONi,S'=A1.ARMS/bARRIiERS SHALL BE M PLACE AT PRE
PL.A TER INSPECTION
POOLAND/OR SP.A.
17,000.00 LS
1aS
IMD COST OF CONS'IRUCT.LO.N
17,000.00
PERAW. M 8I1ADMkRY
'1!11Z
PLAN CHECK FEE
101-000-439.31.x`". $11700
WNSTRUC T ION FEE
101-000-418-000—, 5180.00
WCHANICAL FEE •- POOL,
101-000421-000 $24.00
ELECTR.IC.AL FEE -• POOL
101-000=410-000 $49.00
ALUMMO FEF - POOL
101-000.*Lq-000 ._- $27,00
14
SUB-TOTAf, CONS'PRUC11ON AM, MAN C.H:C"K
$393.00
1* 38 PR&PA1D F '+L1;,9
$0.00
TOTAL PKMT FEES DUE NOW
$393.00
RECEIPT
DATE
BY/�
DATE FINALED
INSPECTOR
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
Insulation
Compressor
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
Z,
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
,
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: