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0004-031 (RPL)
LICENSED CONTRACTOR DECLARATION 4J hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9:(rommencing 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 ;45.1/x/' C5 Date --`1 Signature of Contractor _ f OWNER -BUILDER ECL'ARATION I hereby affirm under penalty of perjury that yam exempt from the Contractor's License Law for the following reason: L ( ) 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). ' ( ) 1, 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 perry it is issued. ( O A fiave 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 STATE FUND Policy No. 229-00-0019334 (This section need not be completed if the permit valuation is for $100.00 or less). () I certify that in the performance of the work for which this permit is issued, I shall not employ any person'In any[nanner so as,to become subject to the workers' com ens$tion laws of�Califomial and agree that if I should become subjectto th workers' compensation p(ovisions of Section 37,00 of the Labor ode, sh Of {With comply with.th Sic.provisions/ ate: p-1� Applicant -9'•J C- .. ` Warnin : Failure to secure Workers'/Compensation coverage is unlawful and shall subject an employer to crirninalfpenalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 37.06 of the I ahnr f;nde. interest a.nd 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 worli'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 thefbuilding,,, construction, and hereby authorize representatives/of this City to a •ter upofi the above-mentioned property, fo in ti tion purpose�s� / Signature (Owner/Agent)/��+Y' Date <r� r "" �I gyp` �'" BUILDING PERMIT PERMITk DATE VALUATION LOT OW4-031. TRACT i $14.200,00 JOB SITE APN ADDRESS 47—$90 VIA MOT ESSA - OWNER CONTRACTOR/DESIGNER/ENGINEER CMADAY & COMPANY :SIAL HAMPTON ba V".P CATION POOLS 17480 R 17fH M. #106 9522DONMI)SON' 1D. Tuiril),+7 Cr`1 92780 LUCEWE VALLEY CA 92356 i C`.BL# 4"5 USE OF PERMIT 1 -1�QO` � S > • A. POOL&SPA ONLY,.ALAWSiBARRIERS SHALL BE IN PLACE AT PRE " PLASTER iMNPECTION ONLY POOL AND/OR. SPA 14,200.00 14 E.W. MA's COST OF CONS%72UC77AP7 PIaP,],I CHECK PEE 101-000.439.318 $103,30 CONSTRUCTION liZE 101.000-418-000 $162:00 MECHANICAL FEE -- POOL 101-000-421-000 $24.00 ELECTRICAL FEE- POOL, 101-000-420-000 $45,00 PLUMBING FHX -- POOL 101-000.419.000 $27.00 SM -TOTAL C©N81-A' U'af1OBF AND P1.,AN' CBECK US$ PRE -PAID FM- I I RECEIPT I DATE . OlAil FF_R_WF1"?�S DLIE 1NOW i 14,200.00 INSPECTOR $363.30 $0.00 r -I INSPECTION RECORD �p -OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS z.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 Insulation Compressor 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 BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover V Equipment Location Underground Electric _ 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 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) COMMENTS: