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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 -i l
Professionals Code, and my License is in full force,and.efffect.
License # Lic. Class • Exp. Date .
. € 95►t� C53. i 1 l.`30lR7A
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Date /+(Af � signature of Contractor
OWNER -BUILDER DEC
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 carriE, & policy no. are:
CarrierAT Itlp;j Policy No. k:39Q3%��I
(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 man ego as to become subject to the
workers' compensation laws of California annd agree that if I should become
,r' . ...
subject ,to the wog`kers' compensation R^ovfs�ons of Section 3700 of the Labor
Code, Vstiall �fforthwi h comply with those�p-r'o ' sjQPs. .
Date: ' a //� ¢ Applicant
✓ S
Warning: Failu ,e 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 persomat
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
correct., I agree to coml
construction, and heret
the above-mentionedpl
Signature (Ownei/Ager
t BUILDING PERMIT PE M #
DATE�. VALUATION Yy ����y��pp �r��,,�•� LOT \• 0;! 10-AWTRACT
)OB SITE " [ APN
ADDRESS]
OWNER +' CONTRACTOR / DESIGNER / EN INFER
>FSAMM:MYt=UiDW:E VAMCbY ?GC2S W
Ot:'R1SCiCN
79-33' :C7bw,r cauu ►T 53300 AVEARA
'i.,n Qmm& LAQUWTA CA 92252
2893
USE OF PERMIT
P001'lil PA. ALAIZMSIBAR tIERS SHALL bg iN PLAICE AT PRL�,PiA11I'Vk:
WSPEC` OW. POOL ZQUIPIi tNT E)W. GURE NOT iAitYLUF)ED
POOL ANDIOR SPA Y400109 La
9SMUTED C081C OF CONSMUMON 1710W.001
;1JI 10A CHECK' FRE 101 000.439.318 $1311.,00
GLila:"` A.?.iioil6:.1W >z`D1I~: 101-000-418-000 $190.00
MTI?f:'!~"IVAL VEP .. POOL, 101.00OW421.000 $244
F.LSLIrm CAP11 AM, .. POOL 101-000-420-000 $43.00
PLi1MINO ME -- F'OtX 101-000-419-0(X) $27400
8C3Q3�'f C?`k. TJr-'."l°s.!' N .A.II 3 PLAN C1MCI
LESS M-PAID)FEE10-1 $0,00
)plication and state that the above information is
II City, and State laws relating to the building
orize representatives of this City to enter upon
for inspection purposes.
RECEIPT DATE BY' DATE FINALED INSPECTOR
Date
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
o BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Electric Bond
Main Drain
Pend Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
�V
—
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
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
f
Gas Test
Appliances
Final
COMMENTS:
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)
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DeLo.ndtsheer Home
79335 Desert Crest
La Quinta
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BUILDINGAFETY DEPT
OVER
TRUCTION
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Construction -`
Pools Spas Fountains
(760)564-3655
Lic. #658996