0311-113 (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
Date i 4�'r Signature of Contractor ru"I !� �✓
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.
4_r) -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 i' r*,Oy'�-MS�.G? Policy No. 046-6409••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 forwhich 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' compensationrprovisions of Section 3700 of the Labor
Code, I shall forthwith comply with t ose provisions.
Date: 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 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 forinspection purposes.
=Date
t PERMIT #
BUILDING,RERMIT
DATE '� VALUATION -• LOTS �' TRACT
65
JOB SITE
APN
�y
ADDRESS r s� L:S��TTFsi�� .�rk�C
•.
OWNER
CONTRACTOR /DESIGNER /EEN61NEER
D AyniJ:EVZs13C14T
rALTyJIA POOLS & 9rS CMPMiC
PO BOX 1716
86-100 t MME' 5.4
1Aqurb1sA. ::A. 92233
COACk31~7:. ,A CA 9223`6
Cm;:))398. 222 CHL4 00355
USE OF PERMIT
POOL,AMDADR OPA
POty;., SPA, 8RQ(AVS121-58.1995] FIRL, IT (493 ACLAL).
ALARMSI'f3.t'1RPLIE". SPri.Fti1.W39 IN PLAOR,AT P.P.&PP"TER RISF'RC-'f`PV.7
V,QUr3}MMT ENCLOSURBINIOT.rNCLUDED
E'OOLANDJORSPA 1.91000,00 LS
. lkfiM fd+'l.�d.le.bf%;'l.4S7 �7� ���, :�or7.+�d' 9,L.�p G�n°.7,.&kl.S ii
WIMw�'L7.00
Pra-M€TME SLP11f1.MARY .
PLA�1 C REC:3 FEE 103.000-439.3318 $129.70
Mqy1` UC ION FEZ 1101-000-418-0001 $19fI 00
A ECHA2t.ICAL VER -- POOL 101.000.421.000 Sa24A
Elr1?L".F1'xtf'.`.AL.IME .e POO] 101-000-420.-000 $4100
P 1, UM 5 M 011 .E -- P001, 101-000-419-000 X27.00
ic
--anQasuc;arrir,UEC
$47170
LESS M-PATDFIMS
$0.00
NOW
J
ENO 7 2003-
CITY OF LA QUINTA
FIMANHIS: nr-a•r x' I r•: °LIZ
RT y, J
BY
DATE FINALLD
INSPECT
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
nnwall _ Int I afh
I Final
BLOCKWALL APPROVALS
I Bond Beam
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underaround Electric
POOLS - SPAS
PLUMBING APPROVALS Gas Test — _ L - v
Electric Final
Waste Lines Heater Final
Water Piping Plumbing Final -
Plumbing Top Out Equipment Enclosure
Shower Pans OX for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Pioina
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
i Temp. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility