9903-178 (RPL)i
LICENSED CONTRACTOR DECLARATION
thereby 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
W - Professionals Code, and my License is in full force and effect.
O License # Lic. Class Exp. Date
C, LO t
W7/311
7/311
{
~o Z r- Date i t Signature of Contractor
CD O
F- o OWNER -BUILDER DECLARATION
U.�
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
t1 License Law for the following reason:
.V) ,
Z (.) 1, 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).
C'') ( )t_I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
O� rn
.n .,Q WORKER'S COMPENSATION DECLARATION
o �' I hereby affirm under penalty ,of perjury one of the following declarations:
Lo
'Q () 1 have and will maintain a certificate of consent to self -insure for workers'
X Ul
LL compensation, as provided for by Section 3700 of the Labor Code, for the
O Qperformance of the work for which this permit is issued.
M ;Q U, (,,tf I have and will maintain workers' compensation insurance, as required by
p U• Section 3700 of the Labor Code, for the performance of the work for which this
rn• H permit is issued. My workers' compensation insurance carrier & policy no. are:
.<+ t Z Carrier Policy No.
0�0.0 1TT:�M1t; NT COIN -11? TINS ;l :+,*'*''%0301
J(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 provisionsiof Section 3700 of the Labor
Code, .1 -shall forthwithi comply with those provisions.
Date:! f $ ' )Applicant
Warning Fail'
u � 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 C.ppli:atiQn io horoby mala• to lh6 Diitclul of Bulldit,, anti twely
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
F, 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 propertyfor inspection purposes. f "sr'
Signature (Owner/Agent) to�'f! { t�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 9%U-178 TRACT
3117199
JOB SITE APN
ADDRESS 447440 VIA INI)j.aNUSSA
OWNER CONTRACTOR / DESIGNER / ENGINEER'
��iY-K.E Y 6.:1.tr.:M CyON11,"1'13:1fC;'i"ION CYAM"tIl[, alk POOL CMNS t RUC'I ION, INC.
73-929 S1 MARD WAY 7S -71O LA PALMA m., LA QUINTA
Pfid..M..I"JI:'SW OFA 92260 PALM 1J`P(ST'IZ`, CA 92261
t76tlPM-602 CD1,4 1 M4
USE OF PERMIT
+e".,�'3i,e��t'±��.aA.�Aii.4�• f�L1�1E�i47�/i2��1�2�3'�'� 1�2�'a'i".���.iNt'I.fi.C,L.r�'�`
POOL €3;.3£Kv.00 US'
S+ �"� 3y'�`UTED COST OF CONSTR.UCI ON
P,'RiiUT FEE SUMMARY
PLXN �..k` IECK Fli
F.`.(3t:1S(''DcMI7'd7N ITE 1A1. -QW -4-M0 i -4)8-f1110 $19s.an
�tMF',C 1P%NK';,t 1,1`I,; �-Pt..)OL 101l0 -421 -Wo $1.1.00
1wL1~C!TR1CAL ).1..G ..P+ 0L 10t-000-420-000 $45,00
'P1.t.3M)31NG.HX1 POOL 101-lld)il-404-000
3..1ti c l' ►.f C0NK_rR .lC*I7?N KNn RKAN CHE1:3~; $4?2.170
'LESS PRA1.4"�1. D PI:I?;1 $00)
TMA.I. PERMIT Fr f;.14 TWE NOW $422.70
G�
RECEIPT ,` DATE 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
0. 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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond -
Footings
Main Drain ell
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping ,�ko
PLUMBING APPROVALS
Gas Test
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 Piping
Gas Test
Appliances
Final
COMMENTS:
i
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)