0111-274 (CP)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
552140 C5313 Z�?IY:
Date If,) ""�� Signature of Contractor !� t»�`ttd•� ut''�
1._
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury ry 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.
P I have and will maintain workers' compensation insurance, as required by
S cfron 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 STME 1rfdND Policy No. 1625OW-01
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date:.if + t«tF Applicant 7t�YE� n,R A/
Warning: Failure to secure Workers' Compensation covbrage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a resL:lt of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation -of work for 180 days will subject permit to cancellation.
' I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
;the above-mentioned property for inspection purposes.
�Y
Signature (Owner/Age&). ^,M t,r?� �t✓iL*� moi'' Date ''` ���'
,
BUILDING PERMIT PERMITk
DATE VALUATIONy LOT -� TRACT 201^1
1 �
JOB SITE
ADDRESS l�a�e��l
APN '
OWNER
CONTRACTOR/ DESIGNER/ EN &NEER
DFAMT CT1.Nrs Ii1;idL+�T.,C PNMT
CAT, PAMIC" POOLS
78.600 IMNY 111
RID. BOX 1814
3 Wit?"r FT%J C,A, 92253
P +f S4,PRINC$' CA 42263
aw
USE OF PERMIT
POOL,A'P.' DIOR WA
COMMY-Mc:7Az.; U07 P11R PTXr3.LTH 1)ZF.AIS'.•i"lbar".5NT.P6.Pk'1.0V1e_ID PIANS
POOL AIN IWOR SP,A lag
WITUATED MSf Off' C63NS'T. J'CINTON
01 -WOO -4, 39.31 113 S20610
1014000.418-000 $317.00
?S:CC H,A141V kL FFZ -- POOL 101;000-121-000 MOO,.
i' , POOL 4. n -t bo-s5.2!"I•�000 $4:".;.00
'KAYMBING MR. -4 Pool, Wf-bhO-419-000
oc r 2,9 znal
CITYCIF LA®UINTA
FINANCF OEPT. ,
OR) T3- ia0`f, 5 d�t)pd #.Cly"t'Se3 1' ,old � i�T i i. t' :
$619.01
4 LESS PlUt-,1•'AM N =t
'6t1. C4
F
RECEIPT
DA/T�E 1
BY t
DATE FINALEY INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDI o�AP OVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap - - Z
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
Set Backs
Steel
Electric Bond
(-
Footings 5- y - z
Main Drain
Approval to Cover
Bond Beam
Equipment Location
Underground Electric
40l
_
Underground Plbg. Test
��aZ �f�d
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
L%.,.7, oee
-
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation]
Gas Piping
Gas Test
Appliances
Final -
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _ Z
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)