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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 nd effect
License # Lic. Class Exp. Date
taSit 9 6 C53 t�lf _ 1 1. F13012'
Date _ . _ _ _ _ Signature of Contractor
OWNER -BUILDER DECLAMATION
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.
STATE 1rk.11s1.) 13"0102M
(This section need not be completed if the permit v5luation is for $100.00 or less).
() I certify that in the performance o the work'for which this permit is issued,
I shall not employ any person in any nner so as to become subject to the
workers' copensation laws of Cali o�nla, and agree that if I should become
subject tJ thl workers' compenseti"ori roVisions of Section 3700 of the Labor
Code,
1 s I rtl1with comply with
Date: Applicant_
Warning Faure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his,_
application.
1. Each person upon whose behalf this application is made & each person at r
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the b ilding
construction; -and hereby auth6riz4 representatives of this City to ente upon[
the above-mentioned property1for i6pectiogpurposes. f"
Signature (Owner/Agent) Date 1
t•
BUILDING PERMIT PERMIT #
DATE VALUATION LOT (}1,0SS C`73 TRACT
JOB SITE
ADDRESS
APN
43-05 GALAXY
OWNER .
CONTRACTOR/DESIGNER/EN (NEER
MF f� iir^.1.L,i0L1i,
FAMMY POOL$ CiO'Ng'Y°%UC".�'�'�C N
43-05 GALAXY
53300 A'bEWDA RA10122
LAQIiIM CA 92253
L.QUINTA CA 9225
(760)564.3655 C..I _0 7893
USE OF PERMIT
POOL BI3!!XOR IPMA.
POOL &. SRA ONLY, Pi:'Ri+ IT s.OES i (Yf INCLUDE i3WCK WALL ALARMS
S.l,T,f?<.LL lits IVIS!',A.C,LY0 P'O' Plti PLAUT.ER. INSPECTION,
P001, ANYMOR SPA 1346 .00 lz
91.E7b. Aaij) COUT W.R.' COV911RUC1.601
15I0M.00
MAN fM`HECK l;.i Z 101.000.4 99 318 SIO 1 S0
C(M3ilUCTIM;fte 101-000.41&.000 WX00
V.&C <A,?1ttnA«,, VEX -- PCIOL 101.070 421-000 $24.00
Yd.,ECTRiC'AL gtErfr, .a POOL 101-000-42.C�.000 245.00
PLIUM'01.1•ICi FEE POOL 1€31.000-419.000 WIWI
H
OUDUPY M,
I; ! i = &SIUS CS'OWP.AT)Fl+_12„`31
X00
'¢ A PER-Wi t' YKE-S DUE ROW
UG -9
2001
1, a
_-. FliVAtdCE npj
RECEIPT
DATE4 ��E�`j"
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 Wail Insulation
Condensate Lines
Party Wali 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
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
Shower Pans
O.K. for Finish Plaster
Sewer 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)
Stolioff Home
43605 Galaxy
La Quinta
IAccess Wall
CITY OF LA QUINTA
BUILDING & SAFETY DEPT
APPROVED
FOR COMSTRUCTION �
Xn �%
Street
Construction
Pools Spas Fountains
(760)564-3655
Lic. #658996
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