0102-004 (RPL)LICENSED CONTRACTOR DECLARATION
°I, herel:f affirm under penalty of perjury that I am licensed under provisions of
;haj3ter 9 (commencing with Section 7000) of Division 3 of the Business and
�Pi4essionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Datea Signature of Contrae'tor ° �3
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).
( ) 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
WORKERS 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.
,(v ), 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 TAT
Policy No. 229140-0019M 0r,f9M
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) l.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 aoree that if I should become
subject to the workers' compensation provisions"If
1 Section 3700, of the Labor
Code ,°I shall foflwith comply with th se prdvislos,k�
Date:.. n�' Y3 - Applicant—-
Warning:
pplicant,._.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 SafeZW-T
for a permit subject to the conditions and restrictions set forth on 440 1
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 a4oid if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of.work for 1'80 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 property for inspeg� ion p rp,oses. • ��; � ��
Signature (Owner/Agent)! f W Date
BUILDING PERMIT PERMIT#
DATE,I�.' VALUATION LOT 0102-IX4 TRACT
JOB SITE "
ADDRESS
APN
47-930 P'�� SO V diaH.tea..
•• .•
OWNER
CONTRACTOR/DESIGNER/EN (NEER
'C:AIA,:rd AY &• i~'Q WIATY
J. -W, HA. `` ON &1'1VAC A71ON POOLS
174 WE. 1`ITH OT, #106Irtf
SM, CA #27GO
UTC,'PMTR VALLEY (CA 92356
(760)7,48.6645 CB1R, 4335
USE OF PERMIT
P001. AM/rAR SPA
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FILL&MR 1143 CTrON:P t, XQ+U,1.P'A/Yk?N'r LW'CLO URE IS NOT fNtLTED
POOLA&sI96+A SPA €.10015.00 U11
ISIM &AIrD COST OF COPS11MUM1011
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P111
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r 02r STP 13C 111 14 F&E 'A 01 -000-e1 18400 $16100MrKA
I�Td�`i��C:AL � � � �- F001, 101.0 0.421.000 V4.00
E NGS IUCAt FL, n •14Rph, 101.0010-12.13-000 V15.00
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TOTAL MGM M'S DQE+' NOW
RECEIPT 1 6Y D/�f LED INSPECTOR
t
. .. _ . S.H. ..
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs .
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
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
,I
Gas Test
Appliances
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)
Final
COMMENTS:
%
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