9805-022 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapt�:r 9 (commencing with Section 7000) of Division 3 of the Business and
Professional;:LCode, and my License is in full force and,effect.
Licse # Lic. Class Exp. Date
C53 r 10/31/38
Dete , - ••' � ` 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
perfo ance 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.
(This sectio e d not be completed if the permit valuation s fog'$ 00:01 oar' 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 a����s-that if I should become
subject to the workers' compensation provlslon of" Section 3700 of the Labor
Code, -I shall forthwith comply with thoselpro Bions.
Date:` -� of 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 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 per 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 vAill subject permit to cancellation.
I certify that I have read this application
Correct. I agree to comply with all City,
construction, and hereby authorize rep
the above-mentioned property for insp,
nature (Owner/Agent)
state that the above information is
State laws relating to the building
natives of this City toyenter upon
purposes.
Date ^r 1
BUILDING PERMIT PERMIT# CONTROL#
��yy�
DATE VALUATION LOT. 950 022 TRACT % p
a B
K 1 Il.11 1.
JOB SITE
APN
ADDRESS
-
7IL9A0 A/1 A CA R ViVl
OWNER -
CONTRACTOR / DESIGNER / ENGINEER
T.D D18URT DEVELCiMO NT
CALIFORNIA POOLS cCc SPAS
•79-295 RA14CHO LA QLiLN"I'A. DR
74-725 JOIN .DRtV ,. A. . .
LA QUINTA. CA 92253
PALM DFSF:R'I' CA 92260
(760)340-9000 CBL## 35.5
USE OF PERMIT
RA I
Dr, Y 0 °5 1998
POOL ANDIOR SPA K 1300.00 LS
QUIN
uS'1'.CMEA"i l+'D COST Dig' CONS.. R OCT ION t�S,i11113.Ot3
PEItMff FEE SILIAI I ARY
Pf. i>;.1N CHECK.:FEE 101-000-439-318 $111.15 _
C-0NS'rRLCr10N FEE 101-0004.18-M $171.00
MECN Q—CAL FEE -,. +0t3L 1014)00_1r1_000-
tz.fxc RiCAL PTiE -- PO01, 10.17000-420-000 $•1"5.1)0 '
PLt MBI -NO F03 F -- POOL 101-000-419-000 $27.00
Sto'B-•lOTAL,CONKrRUC7iOt4 t4:ND PLAN CHECK.
LE -Ss .P12E4 A1.C3T828
TOTik.L PER11'ITT F ER.S' 01,11? NOW 5379.15
RECEIPT
DATE
BY
DATE FINALED.
INSPECTOR
G
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 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 Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
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 Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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