0302-109 (RPL)' i..
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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
Professionals Code, and my License is in full force and effect.
License # _ _ Lic. Class Exp. Date
C+ 1 1$ c53 101110
;�� 4
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's w
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 r
contractors to construct.the project (Sec. 7044, Business & Professionals
Code)..
O 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:
k!( .r)^^I'have and will maintain workers' compensation insurance', as required by
Seehon 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:
Cartier STAFl+..COMPROIRATI Policy No. ft46.6161f-69 +
(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 that if I should become
subject to the workers' compensatiop1provisions of Section 3700 of the Labor
Code, I shall forthwith comply with the se pro isions.
Date: _, - = t Applicantr;,�8'
Warning Fallure3o secure Workers' Compensation coverage isra'Safety
and
ji
shall subject an'%mployer to criminal penalties and civil fines up to
addition to the cost of compensation, damages as provided for in
of the Labor: Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Dire
ctor of Buildinfor .a permit subject to the conditions .'and 'restrictions; set application. + '~ 1. Each person upon whose behalf this application•is made & e
whose request and for whose benefit work is performed unddr or pursuant to
any permit issued as a result of this applicator: 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 representatives of this City to enter.upon
the above-mentioned property or`spection purposes13
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Signature-(Own-I...Agent) ✓V, 1. 5,1-T i" Dat-�
A)
...BUILDINGPERMIT PERM T#
DATE SL VALUATION �•y•�•y, �� LOT ~109
TRACT
JOB SITE
ADDRESS
APN
OWNER'
CONTRACTOR/DESIGNER/ENGINEER
:li'mov>`�2:�'. ir"'.RE50 ,C:omwJAii':Cfa,!'€ c
{MAUA`s^r,RMA POOM" & SPAS CMR MMI (10
200 R WAM:I3GTO14AVS 0100
96.100 AVE'M E 54.
F2010AIDID0 CA 92021
C:Cy.�AC �fry9.A ,
CA 36
`?60)398.9222
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USE OY�FPERMIT
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skis PW'.1ION; 1r+,��;�FPM T FNCf.,0SVR3{'NOT 113CLUDIRD,
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PLAN C±hiECK YM 101-000-439-318 V 2,32, 70
CCMT.rtUC,T.'s0N FEE -.1011-000-4-1.9-060 $199.00
WICHAWC66FER P004 101-000-421-000 $24,00
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RECEIPT
DATEr
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BY a
D E F ED
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INSPECTO y rpt
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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
Bond Beam
Approval to Cover
Equipment Location
R
Underground Electric
Underground Plbg. Test
_
_
Final
Gas Piping
• PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
W.'er Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sevier Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
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)