9801-069 (RPL)LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of
hapter 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
h5F6i28� r C53 /T1,z
I0 31/-98
,4Date � i t_� ! 4 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 structureis 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.
I.
.TfAT8,FL, CkI.f 9S-(301361.6$
(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
Code, I shall forthwith comply with those provisibnsr--^ ""
Date: 1 %4.1,1,,,.. Applicant
a
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. 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 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 applic
correct. I agree to comply with all
construction, and hereby authoriz
,tthe above-mentioned property ford
'� Signature (Owner/Agent)
state that the above information is
06tate laws relating to the building
ntatives of this City to enter upon
purposes.
Date
r�
PERMIT# CONTROL#,
BUILDING PERMIT
50_1?709 65-32
DATE ` VALUATION LOTTRACT
�r r $15.000.00
JOB SITS I
APN
ADDRESS
4-62.5 JACK NI C KLAUSI
OWNER
CONTRACTOR / DESIGNER / ENGINEER
%SL .LAND Ii
CA.LIR_)RN1A POOLS d'c aPAS
79-9 5 ,1 GA BLVD
74-725 JONI DRIVE, 0,
LA C1UINTA CA 92253
PALM DESERT CA 92260
(760)340-9000 CBL# 335
USE OF PERMIT
i��7t7
Pool
POOL rt NDIOR. SPA 15,000.010 LS
FST .IMATED WSW OF CONSTRUCT ION
i",i301f.t1>e
'PER.I1i'IT FI:E SUMMARY
Pi.1`WC1WMr.EE 101-000-b9-3.15 Sitf5.311
CONS RULE ONFEV 101-000.418-000 316100
MECHANICAL :FE8 .. Ef.X .101-000-421 , $1.00
'8LF_C`1`RJCAL-w!?OtJI. 1C1iAt1Cf-d 0x000 $45.OU
PLU4BiNC Ffm PO4'3;. $27.00
PAID
4 'JAN 14 1998 ' 4
..
l
CITY OF LA AUNT '.;:.Y r
4LTB- TOTAL CONSMUC110 ai.AND P4,M- C1E CK
$363.1tMi, '
PM -PAID ITES
bU.t)ti 1
TOTAL PERAM T F, < DUENOW
5363.30
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
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
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 -2 -Irk,
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
o9k,4RMS _vA1574/IC0
rnpDe,/ MA•n9E: 7 2C L KO
*t sop 3,*
2, _54JOE-As
Z AvAN DloaeS CGRje,4ryc3 rTaL
Gclef 'T ffOtJSE
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)