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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under Uo:.Jsions of BUILDING PERMIT
Chapter 9 (commencing with 9,ection'7a00) of Division 3 o hiI _Business and DATE i VALUATION LOT
Professionals Code, and my License is in full force and effect. ! �/ /f ;c•sli�
License # Lic. Class Exp. DateJOB SITE
7:121005 �
r C-53 k� '✓
430104 ADDRESS
S W1-4365 CALIX E 79
OWNERDate'Signature of Contrac '
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.' 70441 Business & Professionals
Code). 4
( ) 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 EyFPolicy No. k
f
(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'f.compensation laws of Californi , and agree that if I should become
subject'to the'workers' compens0oF-ovisionsof Section 3700 of the Labor
Code, I shall fo with comply with t �e proy) iori
ate:,*/ ✓ Applicant lie-
� ,�,��G�.—•tom Y✓',,, ter --cam^—
Warning: 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,ttie above information is
correct. I agree to comply with all City, and State laws relating to the building
construction; and hereby authori4d representatives of this City to enter upon
the above-mentioned properly for inspee ioowp,roses.
Slg' nature (Owner/Ageu�t � � �r - �'- Datee"If 0
MR- AM/OR bas. v oncus-cy
?8-A35
LAQUWA CA
USE OF PERMIT
PERMIT #,,
TRACT
lr APN
NTRACTOR/DESIGNER /ENGINEER
VALLEY POOL & SPA
92253 PLM 0"1903 CA 92261
(9fil �'li3�SAsJ 'f?I:ft� 2565
INST A." Ai£+VV ii:ICd-HT.N' Sf~tI+l:A!)�.,,t�, MAIIN DRMN TO MMSTYNG Ia004
' ,Y003:.ANDiOR SPA
$100010 Ile
XFMWX 7D Co'sT CA''C'ON' R17C.M(Aq a+I(M W
EILEt'-'TRICIA11 FEE -v i?00) -101-000420-000 $4106
PLU M 31140 !3 ZE -- POOL 1 fe l-f0r'J4 3 9.10co W400
DEC 17 1001 ToarAT,'vE=WF v.5D t,ENow 72—M
CITY OF LA QUINTA
FINANCE DEPT. /
RECEIPT I DATE 1 ! I BYE- e; DATLFIrykLEQ, I INSPECTDO-6.1
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
0. K. to Wrap
F.A.U.
,Framing
Compressor
,nsulation
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
1 BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
PLUMBING APPROVALS
:+
Underground Plbg. Test
Gas Piping
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
� CJ
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:
FROM : MARY CASTORENA
PHONE NO. 760772585Ei Dec. 17 2002 05:46AM P2
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