9803-008 (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
P.r?fessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor �•I
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 3 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.
STr1,'1T .FIRD 6 6�9ft-fl0fffat6i�
(This section need no be completed if the permit valuation is or $100.00 or ess).
( ) • 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 Calif ornia,,,andqagree that if I should become
subject to the workers' compensation proVlDyns of Section 3700 of the Labor
,P,ode, 1-shal1,forthwith comply with those pro sees.
`'Date: _21 I r 1 6 Applicant s� ' . .
Warning: Failure to secure Workers' Compensation covera 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 ai
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
co4struction, and hereby autthorizek-representatives of this City to enter upon
the above-mentioned property for�nspecti purposes.
/Signature (Owner/Agent) o Date %9 /9C►
BUILDINGPERMIT PERMIT# °°NTRDL#
DATE r VALUATION LOT .9893.008 TRACT Q 6 ®sw
8
V VV
`P� �.f 1.Oi9fl.(90
JOB SITE ( °
APN
~
ADDRESS _
CCi�f �t (1 �7 �/ j{Q
s-€ "0 JACK 1V ICKILA S
OWNER
CONTRACTOR / DESIGNER / ENGINEER
F SL LAND 11
CALIFORNIA POOLS & SPAS
*5-440 PGA BLVD.
74-7.25 IONI DRIVE, #A
LA QUINTA C.0 . 922$21
PALM DESERT CA 922£0
(760)340-0000 CBL# 355
USE OF PERMIT
SPA ONLY_. ALA12tNOAtRiFiE-tt9 AitE TO BE OPERATIONG L'PtOk TO
EN-CAPIPR PLASTER. INSPECTION.
POOL .ANDtOR SPA 11,000.00 LS
MAR 91998
��1A �,aiV`�,P1�1 1
wrym.. Ann) C(3S3 Off' t:()NST.pwiT rI'fO.N
i t,19t90.111�
YERrMT FEE Si?N;[MAkY �
PLAN CH ZK FM 101-000-439.318 S81.90
CONSTRIYC'fV3dFEE 101-0004is-000 :126,00
MMHANICA[LFEE --POOL 101-Ulftf-421-000 $24,00
ELECTRICAL FIT -- POOL i 0l -000-420-000 $45.00
PLLMD31NG FE = POOL 101-000-414-000 $2r.00
SUB -I' AL CONSTRUMON AND uI.AN CHECK
$Y)3,90
LESS 131ti%PA1,'D FEES
$0,00
TOTAi, P1 0111 FEES DUE NOW
5303.90
RECEIPT
DATE
BY ,
DATE FINALED
INSPECTOR
i
a
INSPECTION RECORD
OPERATION i DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
r)rv.vall _ Int I ath
OPERATION DATE INSPECTOR.'
r
MECHANICAL APPROVALS
Underground Ducts
Ducts r
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Condensate Lines
mnar I I -
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond ,
Footings
Main Drain
Bond Beam
Approval to Cover
Shower Pans
Equipment Location
Sewer Lateral
Underground Electric
Sewer Connection
Underground Pibo. Test
mnar 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
.ELECTRICAL APPROVALS
Temp. Power Pole I I -
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
f
Final
Utility Notice (Perm)
COMMENTS:
TFI1c�:, I'VoO&l -SO 87
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