0304-301 (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
C5�11`�TC C ��
�. n�
Date � Signature of Contractor
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.
,.I.have and will maintain workers' compensation insurance, as required by
Secfloh 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 ,A. L CC)tv91? N81e 1 Z Policy No.
D464162-2003
(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 pr ,v dons of Section 37Q.0 of the Labor
Code, I shall forthwith comply with those provisio s? J.
Date: , I ,F 63.- Applicant � f
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 of this City to enter upon ;
the above-mentioned property fo�i . s� ection purpo es �rr eerrg�
Signature (Owner/Agent) ' Date
BUILDING PERMIT' PERMIT# .
DATE VALUATION LOT ���' TRACT
pppQ ��11 {{��►'nn�,ryry
JOB SITE
ADDRESSTr SgF1'Sw�i,.�3P'iVr
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
9IiA1 VWA TSI C.O, F%4MTr COP—P.
C.fs IFORNM POOLS & SPAS (TOP MAN CO:
PO B.OX 114
86.100 VIMIUB 54
LA QU11d`rA CA 42253
COACIM;LA CA, X2236
t160)398-9222 G'11LO 00355
USE OF PERMIT
P0OLAND/OR MA.
..
PUOJ, SPA. ALARMSIS.AR.➢tiERS SHALL -BE tN PIA -C1, AT PRE -PL AS T.'FR
WSPECTION. EQUIPMENT ENV1.0"MYRENOT 14CLf)DED
POOL AA DIOR SM 19,00A.00 i"s
. - nsi�,i�`rWED ti.~iOS OF ClIfX 4n7J.RUCTIO
1910000)
PLAN CHECK: M 101.000.4.39-318 5128,;0
CO1dMUCTION M. 101-000-418-000 W&U0
114W11',ANIC.AL 19BE 1011.000-421.000
1u12CTRIC L FEE .. POOL 101.000-41-0-000 �2S.ttf3
PLUMB1140 M POOL I O1?,000- 119-000 sr, Do
=8 TOTAL C(»MRUC1T0X AMP, PLAN 00><✓i=11
$422.?0
LEW ME -PATI.) FM
$0.00
e
PEMT :N ,Fs DUE INC?W
$422-70
APR 2 9 200
CITY OF LA QUINTA
FINA CE DEPT
RECEIPT
DATE �-
BY ,e! f
D INAL ,
INSPESTO
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
Electric Bond
--
Set Backs
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Q�
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
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 Conduft
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)