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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 and effect.
License # Lic. Class Exp. Date
6561.28 C53 10/31M
'Aignature of Contiacto,
�,Zate
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 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.
(y) 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the'%�ork for which this permit is issued,
I shall not employ any person in any ma , nn 4 er so as to become subject to the
workers' compensation laws of California:Jand agree that if I should Pecome
subjebt to the workers' compensation provisions of Section 3700 of the Labor
J tho�e`pirqyl�sion
96de, I shall f orthw th comply with
Vbate: �Applicant — X
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. 4
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.
Y
I certify that I have read this application and siate that thi/e/albove information is
correct. I agree to comply with all City, and/§4tafe la'ws" r"ialating to the building
I I 'r �,,( f.. / /
construction, and hereby authorize representatives I oWihis City to enter upon
the above-mentioned property for Aspedrii6n' P"urp'osb
Dal
,Zignature (Owner/Agent) / a1111 lit
_M_V V Aw
PERMIT# CONTROL#
BUILDING PERMIT
9701-4)" 4604
DATE lltl.jil,97 VALUATION LOT. TRACT
JOB SITE ]7FN
ADDRESS 841-1-98 HERHFI'AGE'
OWNER
CONTRACTOR DESIGNER ENGINEER
CALIFOR!'I'liv. KY)LS vk SPAS
80-298 RERIN41TAGE
74-725 30.41 DIUVE, M
CA 92251
PALM DESERT CA 92260
(61 4)MOMM 355
USE OF PERMIT
KAN,
POOL iVZ�'47R SPA. I !,(M.W LS
E"S'TIMATE'D CUM, 0.11' CONSTRUCTfON
1131M IT FCC, SR.fNIM.ARY
PLAN CH&.X YEK
VVIII
&M*01A1WCAf.. K'�CX, 101-000-421-000 r, 0 0
M rk'�VRIOM-,, Ai 01-600-420-C" S45.64)
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ONSlROCTIGNAND MAN CHECK
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nyrm, prRAli"r VCES 0k) F NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
&PERATION
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
'F�haust 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
I
BLOCKWALL APPROVALS
Steel
4z 4�4
Set Backs
- __L_
Electric Bond C-/
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 Cut
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final �11�1 7
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)derior ROceptaicles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)