0202-014 (RPL)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
§1461,1 C s i fl'i/31 iZC
Dater, b/_ Signature of Contract.s %��
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. 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.
*'1(,6' 1 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 STATE FUND
Policy No. 0461046701
(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' compensation prow isions off Section 3700 of the Labor
Code, I shall forthwith comply with,those�/provis'igns
Date iii;" Applicant _,rri�i
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 the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives o,,this City to enter upon,
the above-mentioned property for inspection purposes. ✓ s:.
Signature (Owner/Agent,) , � �� %f`1- e. "— Date" s�
� .
'BUILDING PERMIT PERMIT#
f
DATE 7� /� VALUATIONLOT _ �Zt"a'� TRACT
f
�OWM 22
JOB SITE
APN
ADDRESS 81"MY0 00I; r MEW
OWNER
CONTRACTOR / DESIGNER / EN (NEER
a X H1 LLC
,MCWT POOLS & STIAS
1694q,VON If TRMA.'t� f909
1.',O. BOX 1791
IRVINE CA 92606
i A, QMT1k CA 922-1113
-
C)OO 3600 3585 CP? 1945
USE OF PERMIT
POOL ANDIOR &
P001, A14ri SPA 014-T . A2 P,itic',1ti9i At'«i2i!?1S S11 A1,L 017, rN 1'd..r` CE, PRIOP
`#O P1t>�1'I '11'F21eiSl'I tyl't.£�Tlc 3'()OG �'C��@l� W; T tNCI,.09URE NO`#'
WC1XIDWID AN PEftN9 T.
Pfrbfll,.t'4'kdt.JOR SIPA. 01lKaUo is
l.'R',1r'.�WIPFIFE SUMMARY
PLAN CHECK TIZE 101-000-439418 1D ,3€►
CONST"RUC'I'IM, f'.h;€+n 10 1 _10044 1 Q:..006;
M'rHANICA1, VM—JVOL 101-000-421-000 `KOD
1W;1; ". pa&01, 101.000-4'20-000 WIN
pLifMilM0 FZE. -- POOL 101-000-439.-000
y
S'/CM-:b1niA'i;., OONS`i.'�.�TOfiON AND
$36.3.30
!r Llama", :I1RE-PAU) DEM
$0101'0
Iola N 4iFL.A Lfa vis CA'
c F~
RECEIPT
DATE J 9 w
BY ;
DAT FIQ1A� O SPEC OR
/ :1
Com/,/ 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
_
a
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 Pads
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
Gas Piping
Gas Test
Appliances
ice.
Final
�y7
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)
171VA5. 105 LIN. FT.
FM 504.50• FT.
S.A. 2.11 X.1%
SPA 951
FOL 4cl 5o. FT.
S:A. 1405 5o.FT.
3
Fg7
D&
vc
ori
.0
CITY OFU' TA
BUILDING &'&9M EPT.
APPROVE
E
FOR CONSTRUCTIQN-)
DATE 59 BY
T-
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