0303-151 (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
C' HIC X"'
�
Date 3, Signature of Contractor -TZ T
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).
as owner of the property, am exclusively contracting with licensed
contractors to construct the. project (Sec. 7044, Business & Professionals
Code). :
O 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,- foe .the
peor ace 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 STATF CO, MPENSA TI Policy No' • 044-61-68-200:1
(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 pirovisions of Secti n 700 of the Labor
Code; I shall h ith comply with t ose prg on Or
Date: .2-1''� Applicant %°' /Ok
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 permif"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 auto ze representatives of this City to enter upon
the above-mentioned property for'inss�e'ctioor urpos s.
Signature. (Owner/Agent) /%'kC � Date
BUILDING PERMIT.' PERMIT 030-3-15i
zr
DATEtc� VALUATION A(3 LOT TRACT
`rE l
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
`ice DESERT DLV.'9T Ck qTr
QA+J WQRNI.P0019 SPAS CXLtP M. .A-9 CC
PO BOX 3716 .:
86.1 as .AN'1� M154
LAQi INTA 'CP, .92259
C40AMM-.A CA 92235
USE OF PERMIT
POOL PMVOR SPS.
NEiCJI�.`sl'Fi..li i iia ti{ CJ.fLlLl.L.Lip, IF 1-M-MM.AT
rOWECTION. QUr � ac �i > i c� ,z ►3tzr3t�.�a: .
POOH,ANDIOtt.VA MOWN 143
:5 &TIME NT` D COST OF E:;OMSi1MC° 'YON
� SI,d4�t1e4Kd '
P00AIT FEE SCT.t19mny
PL K4 CHECK PEE 101.00,0-•39°31!3
COTdSTRUf::`I'.IONYUP 10i-UCC418-(5'00 $19$fi�J
MECHIWIC)l.L PEES , POOL. '101,4000-421-000
ELi+ECTIZICAiL I: E _ POOL' !101-000-420-000
PT:,UMMO BI -Pool 1101 0 0 -4S 9.0GO
MAR 1 t,3
�3. CITY OF LA QUINTA
FINANCE DEPT.
--
-�`c1�.�i, C"ci3J U 3 l TiT+� I`i AND k'IA2'
2a, '? o
~ ' IJOS, Pte,- AID `�'.� s
$0,00
RECEIPT
DATE`Ca,
BY ""^--;.
DATE INgLE6--
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
F•rreptace 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
Foofings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lures
Heater Final
Water Pig
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pars
O.K. for Finish Plaster
Seweri Lateral
Pool Cover
Sewer�Connec ion
Encapsulation
Gas Fong
Gas Test
Apprmnces
Final'
COMMENTS:
_.....
Final
Utildy 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
Uti61y Notice (Perm) .