0102-026 (RPL)LICENSED CONTRACTOR DECLARATION
b& -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
Profess;, ;pals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
623- 0,53 113 PC
Date � Signature of Contractou-•
OWNER-BUILDERN
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
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, for the
performance of the work for which this permit is issued.
`(f) 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 Policy No.'
(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 tG the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, 1. -shall forthwith comply with those provlslonN.E
Date: •r --' Applicant ;...'.a'kL__A
__ -'ri
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 Sectio.,) 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. gypp.
1. Each person upon whose behalf this application is made & each person at.ol
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
.r.
& 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.th`at 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 for inspection purposes.
Signature (Owner/Agent) LAI'- Date. T
BUILDING PERMIT PERMIT#
DAT E'VALUATION LOT TRACT
JOB SITE
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN IN 'FR
CAMADAY' Al, C." JA*r;1?AW Y
:%Eta.: &WP 1"a)X &a VAC Ai'101T POOLS
17480 R 171H ST. 0106
z�, 72 l7ONAU)BON* RD.
T(T'OXIN CA 92780
:I: Y.b�`1.±�1;tNE VALLEY', CA. 192356
USE OF PERMIT
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PLAN NECK, K, FEE. 1010-000-439-318 $015130
C'U.gSTRUC T104 i.&, 101-000-418-04,)o x+162, 04
NITEC1•ANIC L.�..'���cc11+'1�.��., Pool.. 101-�C`l7s421-000 $24,00
2111 71RIC,All 1:MR ,i -POOL 1.01•000-420-0,00 $45.90
spr
PLUM51140 101.000.419.000 $27,00
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RECEIPT
DATEpp"4
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BYj • ,
:
DATE FINALED
INSPECTOR
/ ,/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
r 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
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
�b
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
Sewer Connection
Pool Cover
Encapsulation
`�
Gas Piping
7
Gas Test
Appliances
_��
_ G_
Final
//Sr/Q�
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COMMENTS.
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-
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)