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LICENSED CONTRACTOR DECLARATION
,*Ithereby affirm under penalty of perJury'that I arn licensed under provisions of
-A Chapter 9,�cor�mehbing 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
238947 C-53
Date Signature of Contract I r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor!s
_License Law for the following reason:
( 'P11, w. owner of the property, or my employees with wages as their sole
compensation, will ao the work, and the structure is not intended or offered for
sale (Sec. 7044, Busiriess & Professionals Code).
( ) 1, as owne� 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.Codel'i 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.w6rk for which this
permit is(!��slule(A'-" N&kefs' compensation insurance carrier-& poli 'no. are:
Carrier I . Policy No.
(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 shou , Id. beco'me
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: - Applicant
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 aftorney'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, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a resultof this application becomes null and void if
work is not commenced within 180 days from date of issuance of s ' Lich
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 r " presentatives of this City to enter upon
p
the above-mentioned proper0for inq,(ecrtiqn pftes S.
Signature (OwnerlAgent) Date
PERMIT# _5�0! 41%90L 11
BUILDING PERMIT
41,49
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 44-770 FRONTIMRA DR
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
Al I K ul"ALT04.
MASTER POOLS
73555 HWY I I I
LAQU04TA
P Al M D F SE RX CA W'260
3 4 14)22 7
(6 4 9)146-6115 CAK# 16
USE OF PERMIT
KNk AND/Ok.&PA,
POOL,XND $;PA. ONLY
OX: ZZ 4-i
E'S"FiNUMD COST OF C'ONSTRUCTION
1.2;fwwo
P
?V1,(.ZW14 I(, N., A936 - POOL 1014M421_000
RJ.MC`1`R1CM. F94 -- KXA , .101 -OW -420 -ft)
0)
PLUN1,61NO FEE Pool' .1014VIO-419-0)
CY)
I C-2
S03-TCNAL C.ONSTRUMION AND PLAN CITECK
LESS PrR.E-PAIDIUS
TOTAL PIC R MIT VE. "ES 1.) 1) E N( -)NV
RECEIPT
DATE.
BY
DAT E FINALED
INSPECTOR
UT - 61: j : to f rel",TL I � :I = 19101
OPERATION
DATE
INSPECTOR
OPERATION
DATE _T
I
INSPECTOR
. BUILDING APPROVALS
MECHANICAL APPROVALS
Tet 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
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
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 Oul
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Ublity Notice (Geis)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtums
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: