0401-266 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
FF— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
rl w LO
65612% C5:i Inc 04�, 1 Of311iK
� Z � Date Signature of Contractor
co O � �.'� -
CO _ �
J U C:) OWNER -BUILDER DECLARATION
WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
I) License Law for the following reason:
Z ( ) 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).
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
p Cc I hereby affirm under penalty of perjury one of the following declarations:
U-) Fa- O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
OLO Q Section 3700 of the Labor Code, for the performance of the work for which this
11 0)F— permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carver Policy No.
oD :3 a:t.t'AM CO1v11aERV Fl 046-41110-2004
0
(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 pro"visions�
Date: Applicant's
y �
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 becon)es 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 fof inspection puurposesr
Signature (Owner/Agent) o .% Date
BUILDING PERMIT PERMIT#
DATE VAL�TION LOT ti�Ot" TRACT
IR
JOB SITE APN
ADDRESS �(3_CS<' t �♦ ��" i �1 _,
OWNER
PO Doy. 1716
LA Qua- iA
USE OF PERMIT
POOL AWWOR S'FIA
CONTRACTOR / DESIGNER / ENGINEER
86-100 AVOMI 54
CA 92253 COAC'`IMLLA CA 92236
600}A9f3-C)222 (M141 00355
PoOLfsm 6F (�lN�fZ11.3�.t995j, A��Ai'I;ti. IliA1?RIi.i2S STi,Ail. �
IN PLACE KV PR.w_PLAJTF11 INSPcCTiOR YQUIPMENT FkTC 1J)3UR NOT
MCLUM-D
lrCaOL AN VOR RRA
EM -4K �`YED COST OF CO1'�J5°.1�.Y3Cr4.�(i�
PERARF lt''.l E 9U`J ►,. A) ZY
PIA- R tpHECK FE 101-000-439-318 $122,05
CC,3P4Fa'f'C UCTIC3i.1 RIX 101-000-418-000 $$4.00
AECHWHICAL ME -- POOL 101.000.421.000 WM
I LZC T i.[CIA?,., PER, - POOL 101 OU0420-000 $45.00
PLtT14' IM40 FEY -- POOL 101.000.419-000 srZOD
01.3-TtJ'rn O(?NMR11CI TION, !�``1) P AM CHF01
UFF.r.13 PRE PND EMS
RECEIPT I DATE.,-1
AT : ` BY I DATE FI/LED _� I INSPECT
C/o
18,0MI`,C3
X4(!7'.5
MOO
X107.5
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
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Equipment Location
Underground Electric
3 - J�—
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
-
Waste Lines
Heater Final
r -
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
. Shower Pans
O.K. for Finish Plaster
777
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)