0008-014 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter R (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O Z) M License # Lic. Class Exp. Date
r`dLI LU
/
� r*- 476507 CS i �•.1�34i .
oZO t-- We ' '� Signature of Contractor f'
J U CO OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 0) License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do thework, 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).
co O I am exempt under Section ; B&P.C. for this reason
LID
N Date Signature of Owner
O�
CL Q WORKER'S COMPENSATION DECLARATION
< � I hereby affirm under penalty of perjury one of the following declarations:
A H O O 1 have and will maintain a certificate of consent to self -insure for workers'
K W compensation, as provided for by Section 3700 of the Labor Code, for the
:) � Q performance of the work for which this permit is issued:
n. Q L) ( ) I have and will maintain workers.' compensation insurance; as required by
j LOQ Section 3700 of the Labor Code, for the performance of°the work for which this
L 0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
o' Z Garner ;TATE FUND Policy No.
ao 5 2'20-00 MIT 0020.484
n 0
g (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 Califor ia, and agree that if I should become
3 subject to the workers' compensation kions o�,S' 00 f the Labor
Code, allrforthyrith comply with th vi io/q6te:Applicant llt
VWarning: 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
ynction, and hereby authorize representatives of this City to enter upon
ve-mentioned prope for inspectiopurposes.
re (Owner/Agent). V Dated—LAS
-1 -r)U BUILDING PERMIT PERMIT#
DATE VALUATION LOT COS -014 TRACT
M3,IO
JOB SITE
APN
ADDRESS 4s m Duni
OWNER
CONTRACTOR / DESIGNER / ENGINEER
FRAN'UITF'.&VU
AQUAQUEST POOL
45.040 DIMIDIF
80-975 NDIJO DLVD, -
Z;AQUIM`A CA 92253
PALM DFM-T—:T CA 92255
(/60)345-5070 CBL# . 130
USE OF PERMIT
C4IMMU-1313IL DING
HLOCK WPLLL 14 LM. @ 5' NIUH CITY STANDARD
5 Fr, vmu 14,00 l,F
I+ 6rffMA1XD COST OF CONST.7t"!?G'.l ON
303.10
PERMU FFE 4'Q3Mfit ARY
CONSTRUCTION FEE 101-000.416.0011 $15.00
RIB -TOTAL CONST'RU0,11014 AMD PU41^HECK
$15.00
IT,:SS PR,E--FPAID FERE)
'!.XXI'AL, PRIM IT F'M.S VU NOW
WIN(*
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANI CAL 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
BLOCKWALL APPROVALS
POOLS s SFAS
steel
Set Backs
Electric Bond
Footings r=
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final ! pgni 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
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: