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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
41361.128 C53 +
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
pe'rftormance of the work for which this permit is issued.
F( ) 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:
Cartier Policy No.
wr;:�`! �? f' Ll.111tt7 0,16-.117
(This section need not be completed if the
( ) I certify that in the performance of ti
I shall not employ any person in any ml
workers' compensation laws of Californ'i
subject to the workers' compensatiompr
Code, Irshall forthwith comply with those
Date: `� (t +/� Applicant
knit valuation is for $100.00 or less).
Work for which this permit is issued,
ler so as to become subject to the
and agree that, if I should become
sions of,Section 3700 of the Labor
Warning: Failure to secure Workers' Compensation coverage is -unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth 'on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180,days,will subject permit to cancellation.
I certify that I have read this applicat
correct. I agree to comply with all C
construction, and hereby authorize!
r the,above-mentioned property for ins
Signature (Owner/Agent)
state that the above information is
State laws relating to the building
itatives of this City.to enter upon
purposes. !
Date �!�f
� PERMT# °°NTR°`#
BUILDING PERMIT4935 414-0x3 4 9 3 5
DATE 4 w VALUATION S2f)'(f 00 LOT TRACT
JOB SITE
ADDRESS 794KS NIA #-'.rJ.$M.UL
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
HA`Y.
C.'AUF•OR:MA. POOLS & SPAS -
79-065'V A C:ARM-11
:74.725 iOW D'KL %.E?, 0A
LA QC71AP'P'A CA 9275-1
PALM t;31?4EWC CA 92,2611
USE OF PERMIT
POOL AND'SPA Ot.A,
u AL E?ATICIZI 20,00011% t,
��'�".1't i "1'�i!(i `OST 01 t:(Jt�3ro`�#:�JO' '��' N
PLA:i4CFT CK.t-'F:f 101-000-439-318 $134.55
ICTION ION FEE tot 1000418-000 $20?.04)
llflu�:-[°t ifdtC.r1:L FFA^: -'VO 1,01-000421-000 $tid.13i)
(''sL:tsi TRIC AL F LG' . A'W7.; _ ".101-W0420-000
Cn
V1, Tf1ffl 1NC; Mi -•- POOL 10A -000 -414 -OW �? �' t��
� 01
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10
s1 rj trj'!° ►.:tsr„caNST RUGr1,,ON AN D PLAN r,HECK
S417.55
LESS i. RE—P,Mi) EES
TOTAL P1F.:RMI F F 1'f.»14 Wif0}, NOW
.x+437.55
RECEIPT
D,T
BY
DATE FINALED
INSPECTOR
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 Wali insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
—
Underground Plbg. Test—
Final
Gas Piping
— v—
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 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)