9811-004 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
CSY MW*i
4 't
/Date � 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 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 Policy No.
3TAT1'3i4D
(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, andfagree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
�C1ode, I shAll forthwith comply with those provislo, S.
tuate: f `✓ Applicantf�%
Warning: Failure to secure Workers' Compensation colerage 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
construction, and hereby authorize- epresdntatives of this City to enter upon
sl
the above-mentioned property for, in ecti.. urposes.
f,Signature (Owner/Agent) / >� t-4- Date
BUILDING PERMIT PERMIT#
981 1114MI4
DATE 1$13408 VALUATION it3.800111 LOT TRACT
JOB SITE
APN
ADDRESS 79-08.113 1%IFwSEMAS R &W
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C:';*rT1I1: ' lr#%!x.:`.;1,1.Ci7It$ 'J1!IME.S
SUINITli. !? POOLS
i_333 SO, "t,i" MEE1, 9 E, h.'200
44029 ELKEiORN Tib.
SAN BLRNAkU1N0CA !?2408
PALM, DESPRT CA 92260
f7c�(li3alU-5541 1;'131,# 1(,04
USE OF PERMIT
lkk)L ttt DIOtt SPA
t+<Jvl./SPA. Al..ri#tAi`,�i' BAWtiRRS SFIALL 813 iW rVI' Pkfa-PL,AXWER
t+]SNL
T1NOG% iU4DA:)R 3PA. 13,800.001.3
EST'T1�"{e$' EA) COST OF"COl`dr. TR.1'C' ION'
'ERMIT 1"C SUNIN4ARY
PLAN Cfff,CK. FU_' 1.01-4 w-vq.318 599,45
Ci 1A1S 1 sir rl"PT(lt FIRE M (71-f1(111 A i fi l3()fl V 1%1011
1TtI_X1 iNKVU. VEM -- Pool, 101-000-4r",1.000 $21,00
UA' rRICAL.:FEE -- P00t. J OI -ON -42G-000 145.00
KAttv1141NO FM -- P1001, 101-000-41.9.000 ?e',� oo
81,01-TCYTAI, C'ONS'rRUC"RON AND P!!A *('1 11 CK
PaR Its
I.ESS PRE -PAID FEES
st;.rt0
'I'OTA t, PF1,iMff VF,ES 1)11 E,NO%V
S.34I+tAS
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
r
INSPECTION RECORD
1
OPERATION
DATE
INSPECTOR
OPERATION,
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set. Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
ReturnAir
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall '
'Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS'- SPAS
Set Backs
Electric Bond
If trey
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
�t
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing. Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Z
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low. Voltage Wiring
Fbdures-
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
utility -Notice, (Perm)
COMMENTS:
P/L
ry
p PrP TA
I3UILD.INGSAFET1r DEpARi'M-
EN ..
ACCEP 'ED FOR CONSTRUCTION
SUBJECT T
O INSTALLATION AS PER
�aN ALL ADPL ABL 000 -
POOL SdE
POOL -AREA
POOL PERi£TER
. OEP7H
.COP
'T8 E OWE
. POOL CAPACITY
PW CAPACITY
POOL PU IP
FILTER
FLTER RATE '
Na
YAC
P/L
SCALE h 8- CRAWNO
DAVE AW BETTY MOFF
LRE
OT 2i - DEL Y
LA' Q MTA, CA. '
OuVIA I& / ;biq) 9t0�55Y1
SLNME FOOLS..FAUA MDT, CA.
r -45 C53- zaa
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arm
aEnhrs TFE PRCPER PaoLs
. REPINWi," 3R UW Mq W N IIRRTEN
• . P9iH58W1 5,R'il`!1$PER .