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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am lice..n§ed under provisions of
Chapter 9. (commencing with Section 7000) of DivisioW3 of ihe Business and
Professionals Code, and my License is in full force a'�ncleeffect.
License # , Lic. Class // // / Exo.,Date
/Date
06128 C53
a; f fr,
V..- , - . 1 1.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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 fo r 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.
;STXf H MINI')
(This section need not be completed if the permit valuation is for $100.00 or less
l.certify that in the performance of thqlwork 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�, akd agree that if I should becom`e
subject to the workers' compensation.,provisions of Section 3700 of the Labor
VPo'je, h comply withWo'�e'p�ovisions.
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 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 beh - alf 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 daeys will subject permit to cancellation.
I certify that I have read this application and state thatthe above information is
correct. I agree to comply with all Cify, aridSiate'la`ws relating to the building
construction, and hereby authorize,represeritativ6s of this City to enter upon
the above-mentioned property for iKspeciion pur�oses.'
D
ignature (Owner/Agent) . ate
0/17 BUILDING PERMIT PERMIT# CONTROL#
4367
D 111696 VALUATION
ms.04moo TRACT
JOB SITE
ADDRESS 80- Z34 RURENUT ACC
-6WNER
APN
CONTRACTOR DESIGNER ENGINEER
PdCHARDS.
CALIFORNIA POOLS & -
SPNS
80-234 HF,11WITAOrt
74-725 JONI DfUVF4
LA QPIN-M
CA 92253
PALM Dlis.pwr CA. 92260
355
USE OF PERMIT
PO(Yl. AND WA ONLY
VALWATIZN
118"0110.00 LS
Pk,'AMIT ITU"SIMMARY
PLAN CIAECKFEE,
A 01 -000-439-318
C(AN3TR1JCF10N'R_KH
101-000-418-000
<
I-IATNWAL F"M -- POOL
101-000-421-000 S2A �00
z
EELEVERICAL. FM POOL.
io.1-000'420-000 $45.00
C" D
PLUWNG FW, POOL
101-000-41949.)o $27.0f)
01 C3
00 <
LL
0
C)
UB -IT
S NAL C0N,',*eM._ OC110NAND PLAN 0,4FCK
$407,85
LESS M -P -AB-) KEES
MOO -
TOTAL
$407.85
RECEIPT
DATE —7
BY
77i��ED
INSPECTOR
a, _:
a Al
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
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
Set Backs-
Electric Bond
Footings
Main Drain
Bond Beahi
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
pi
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Bnal_!�—�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
.Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Serwz
Sub Panels
Exterior R ptacliis
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Lifility Notice (Perm)
COMMENTS: