0011-169 (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
63
Date f ? �= .H Signature of 'Contractor
{iFrty OWNER=BUILDER DECLARATION--
hereby
ECLARATION hereby afflrm16nder "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;
O 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.
(°) I have andWill .maintain workers' compensation insurance, as required by
Section 3760 of the Labor Code, for the performance of'the work for which this
permit is issued.. My •workeis' compensation, insurance carrier & policy hol'are:
Carrier Policy No. y"
(This section • need,notbe completed if the permit valuation is for $100.00 or less)...
(,) 1 certify that in the performance of the work for which this peimit'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 tabor
Code, lehall,forthwith comply with those Provisions.a "
Date: w> 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 t0,.&, 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 -ehter upon
the above-mentioned property for inspectionrpurposes.`
r /
Signature (Owner/Agent) �`� s Date,
BUILDING PERMIT PERMIT#
A_
DATE `r VALUATION LOT TRACT
,p rpf� lh
JOB SITE
ADDRESS .
APN
48-76-1 WSTATALOW..'NO
OWNER
CONTRACTOR/DESIGNER/ENGINEER '
D A3 WU 1f33"tF. ,, (YP)x�'�::Ai'r.
C,6 LIPOANLK PO LS &,51)"
P - BOX:171 6
74-725 J0H1. XK1VF,�, t
LA QUIN'1'k CA 92.253
PALM DFMk '.T CA 92260
(760)2 4( -9000. 1 # 5386
USE OF PERMIT
POOLA19YOR VA
£h3 I� fll il'E'1 �AiUA3.1�+ f:11�i iPS i?3il' d�fl ilitg I 1?O!' 1�f�O'j.L$0 D
POOL ANIldO11 SPA 1110-161 00 &;'s
Ir". Er�'s� COL
PLAN C}•I%+;1K1~gE . 101 -000439-318 WIN
COpd;i3'RLIG'TS.ON WE _ 101-000.418-IDOO
. MLAICAL ME.., P0qL._ 101-^,(f0-421.0001 5200
�:%.:ta..C'i'42.�fG,6•JS�.t���'��.,r�..at)ia.; � dkD"@,-�i�{T��:d�l3a�it�if `" ;$r#:G.Ui!
F'UIM81 40 F1 -- POOL ' ' 101' -WO -419400 400 W OO
,.
�±:#3:��'�a��i,�%t�Ca�7�f�a�.'�a[���•��3"�:� �'aht �.i�f���;.
�:��:�.tict
S.�E `� f?x:11-Py�t,WMei
7
. r 54O �t4dJ.. C. 7:A4 9. PIVI 11.5 g'!+ h ,0'i 5.(ffi4J .,
tib�y.Yn%l�7tJ
RECEIPT
DA/rT/E,{, `.
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 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
_ _U�bwo
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
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)