9610-050 (RPL)LICENSED CONTRACTOR DECLARATION
(n 1,hereby affirm under penalty of perjury that I am licensed under provisions of
-Chapter 9 (commencing with Section 1000) of Division 3 of the Business and
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C\I UJ Professionals Code, and my License is in full force and effect.
0 Z) Cl) License # Lic. Class Exp. Date
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Z rr'-- Date Signature of Contractor
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OWNER -BUILDER DECLARATION
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LIJ W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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 & Professional�
Code).
cr) I am exempt under Section —, B&P.C. for this reason
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C\I Date Signature of Owner
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121- < WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declaratiori.s:
Lo < I have and will maintain a certificate of consent to self -insure for wor . kers'
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X W �= compensation, as provided for by Section 3700 of the Labor Code,. for the
0 _J _J performance of the work for which this permit is issued.
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< 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
< S t A i S, AU N D - 12 104 1 tsFt-
[1: U'). permit is issued. y workers' compensation insurance carrier &."Oolicy no. are:
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< (This section need not be completed if the permit valuation is'for $100.00 or less).
_J 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 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 ci . vil 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
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application.
1. Each person upon whose behalf this application is ma ' cle & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a �esult of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued aSra 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 property for inspection purposes.
Signature (Owner/Agent) Date
BUILIJING PERMIT
DATE 10/161!_),6 VALUATION S40.000-00 L O*T
JOB SITE
ADDRESS
OWNER
OCH I
LA,QUINTA C A 9 5 3
USE OF PERMIT
-11001, WNDADRAPA
PERMIT# CONTROL#
" 1 o_.0 TRACT 4215
APN
CONTRACTOR / DESIGNER / ENGINEER
NICIMITIEPOOLS &SPAS
46301ROUDEL LANE
I.A QPTNTA CA 9 M -1
�6 19� 3 422 -.15? 1
CrAL4 19.45
PCKA, AND SPA AND PRCYNt WA10t F-ENWRL3
CSTININU-3) WST 01' COMS"TRUCUO-N 40.000.00
PERMIXf FIFAIC SUMINIARV
PLAN CHECK FE,13 13
CC44-SIVOCTION FER 101,000419-000
IVIRAIAN(CAL FE49 — 1"CO' 101 -WO -421 -ow Z1,00
BIXIM',K)CAL F*hr. -- 1AWL 101-000-420-000
P1JfA4.BP*f.I1(_-' — VO- 0,11. 419-000 0
SLM-70TNL CONIMUC31014 AND PLAN CHECK $6721,68
LESS.VRE-PAID VEVS $0.00
TMAL 11EIRMIT FEES -DUE NFOIN, S-672.68
FiEfEIP�,-,? ,el I DATEi ') _.I �'. "I(/
I BYJ.*�� DATE FINALED INSPECTOR
V J I
OPERATION
DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL. APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0 ' 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 J
Electric Bond
Footings
7 -
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test Yff./
Electric Final
.Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing:rop Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
-Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Jemp. 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
Litility Notice (Perm)
COMMENTS: