9907-524 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of I
L"a fer 9 (commencing with Section .7000) of Division 8 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
B OYIW204
e,
Date Signature of Contractor ej cit.
OWNER -BUILDER DECLARATION
I hereby affir * m under penalty of perjury,that -1 am exempt from the Contractor's
License Law for the following reason:
1, 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. 70�4, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with I licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
I a I lem It,upder 'Section B&P.C. for th § reatq'n
X1.
Date —Signature of Own., iL
WORKER'S COMPENSATION DECLARATION
I hereby. aff irrh under penalty of perjury One of the following declarations:
I(.) I have and w I ill maintain a certificate of cons ent to self -insure for workers'
compensation" is 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 i ' nsurance, as required by
Section 370b,of the Labor Code, for,the perform6nce'of -the work for which' , this
permit is, issued. My workers'* compensation insurance carrier & policy no. are:
Carrier No.
UCMMON 034 T-1LE
(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 th at if I should become
subject to the.workers' compensation provisions . of S�ctioh'�7'00 of the Labor
Co % , i
de, 4hA1114 Mwith comply yvith thoselerovisjohs.-IJ, .4�,
Date� Applicant-'�
U
Warning: Failure to secure WorRers' Compensation coverage s unlawful and
shall subject an employerto 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 empl.pyees.
Any permit issued as a.result of this application becomes null and void if
work is riot commenced. Within 180 days from date of issuance of such
permit, or cessation of work for 180 days willsubject permit to cancellation.
I certify that I have *reaj 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) late—,
PERMIT#
BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS SJ -30 "ENIDA Di",
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
JACK CLARX. GENERAL CONTRACT.OR
it -.710 AVENIDA �;AR'RMNIZA
$1-220 AVEN IDA CAR RANZA
LA QWNTA CA. M53
LA QWNTA CA 922153
C160)w .13 f I Cs[.# 1115
USE OF PERMIT
POOL AWNClIk SPIA
P00.1. OW
L -Y. ALARM&DAMIGPI.,�S SRALL BEINI'LACTE ATTIMIi OF
POOL AANDIOR WA Ltj
M13.1,44,11TED 11COST OF (X)N118TRU1Cr10N
1 1
41
H. AN (THECK J,;M '101-000-439-318 170
$
WAL FE R Pool, t01-000-421-000
'101
CLEC7RICAL Ftt. POOL 84 S. Of)
PLUIVIBINO FhT-- KXX .101-000419-000
S-Ull-1,V)TAI,.CO-NS'FRU.r,n(YN AND PLANI (."J4BCK
$7,74 20
LESS PlUi-PAID FEJFS
$0.110
T(.)'f/kfl PERMIT 10M DUE Nq.
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
1; /WE g,
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
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
�Slt fc/
Gas Piping
-/49
t L
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduft
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. -
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)