0101-266 (RPL)LICENSED CONTRACTOR DECLARATION T
I hereby affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14
W Professionals Code, and"my License is in full force and effect.
-o M License # Lic. Class Exp. Date
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LJJ
r- M ? 614KI1 C53 i9�l�1f2i
8 Z t %Date n;,' 6 Signature of ContractorCID
I— o OWNER -BUILDER DECLARATION
WI hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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).
c'') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
N
z
WORKER'S COMPENSATION DECLARATION
o Ir I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X LU LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m ) 11",have and will maintain workers' compensation insurance, as required by
C5 U Q(. q!ection 3700 of the Labor Code, for the performance of the work for which this
L LO Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
J
(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' comp nsation provisions of Section 3700 of the Labor
@6de, I shall forthwith comply I h those proviS�ons.
Date:l �� �" d Applicantll%% ►��t.. �_ --�,"` ,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
i shall subject an employer to criminal penalties and civil fines up to`.$100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth norp hil
application. �J I'�. t�
1. Each person upon whose behalf this application is madehype s
whose request and for whose benefit work is performed un�pUrs�t to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents; and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to'cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pr pert for inspection purposes.
Signature (Owner/Agent) Dated
BUILDING PERMIT PERMIT#
j
DATEf f VALUATION LOT ��j� 'Pj TRACT
J06 SITE`
APN
ADDRESS
�jy��7�p
X199 �+�p�``+� [!��Y ((�� VIEW
4�1-0-4Y 4 ti4!dAAI'1 'VAI". bT D/eS.(.'M.1`.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MIS+. RUMMY
MeMl'RE POOLS & :14PAS
si-050 W�LFVTEVDMNrE
P.O. BOX 1791
L,A Qi:IN A CA 927,53
.AQUIiTA CA, 12250
(760)360-3W M1,1$ 1945
USE OF PERMIT
POOL "WOR 0PA
POOL A SPA, C N1;Y-ALAK'MVFAR.R1F1ZS 5idrlLL 3Z INI t7F..€ CFQ A:r PRE
PTAMTRIP.. INS.t' OT"PCyW,P001f 9C?Ui.;ZftWT E'e3t;Y.�+S IRY-. IS NOT INCLUDED
��� 'a N•[Ita P�Itr:��
K)O�d ANDIDIR SPA 131009.00 IAS
)RUMIA1 C-01'r'k 011 CONMUCTION
PLAN CHEM, r. FE 101-000-439-318 O70.:0
CONSTRI-LiCTION FEE 101 -000-4 18-000 $162.00
MECKMICAL FEE -- POOL 1011=000AZI-000 SNAM
POOL, 101-000-420-000 $4.5,00
E I.,:JIL9171'i o AR I'�Am 101.000.419.000 WIN
w 'S
810. TCAAL CONTs.t a)i"i1ON PND PLAW C:IM3
t MAD M-aPA%C711
$0,00
'AW" PEFMIMES DUF NOW
r'
RECEIPT
DAT ,' }
BY' / r
y
DATE FINALED
INSPECTOR
= tt
I �
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
Underground Electric
Final
Underground Plbg. Test
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
Sewer Connection
Pool Cover
Encapsulation
_
/2�%OV —4
_
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)