9704-118 (RPL)LICENSED CONTRACTOR DECLARATION
U) 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
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CV LU Professionals Code, and my License is in full force and effect.
E; :)ch License # F g
r ." 'a Lic. Class Exp. Date
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_J 0 OWNER -BUILDER DECLARATION
LU ui I hereby affirm under penalty of perjury that'l am exempt from the Contractor's
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to License Law for the following reason:
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).
1, as owner of the property, am, exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co I am exempt under Section —, B&P.C.- for this reason
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C\1 Date Signature of Owner
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< WORKER'S COMPENSATION DECLARATION
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C:) Z I hereby, affirm under penalty of perjury one of the .following declarations:
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— 0 1 have and will maintain a certificate of consent to self -insure. for workers'
X LU � compensation, as provided for by. Section 3700 of the Labor Code, for the
m_J < _J performance of the work for which this permit is issued.
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< L)I have and will maintain workers' compensation insurance, as required by
O0 < - SXon 3700 of the Labor Code, for the performance .of the work for which this
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0) H permit is issued. My workers' compensation insurance carrier & policy no. are:
-,t Z Carrier Policy No.
CIS _—)
PAULA INSWRIANCE SW9442
< (This section need not be completed if the permitviluation is for $100.00 or less).
_J I certify that in the performiance of the work fo'r which this permit is -issued,
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I shall not employ any person in any marinbri"s; as to become subject to'the
workers' compensation laws of California, ak,agree that if I should become
subject to the workers' compensation provisions of Section
ection 3700 of the Labor
/ode, I shall forthwith comply with thoge provisions.
Date: �Applicant
Warning: Failure to secure Workers' Compensation coverageis 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 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 work for 180 days will subject permit to cancellation.
I certify that I have read this application/aAi state that the I above information is
• correct. I agree to comply with all Cit�,/,ancl State laws relating to the building
construction, and hereby authorize/revpresentatives of this City to enter upon
/the bove-mentioned property for,,infsp�/ction purposes.
S,
gnature (Owner/Agent) Date
. - . f -V
PERMIT# CONTROL#
BUILDING PERMIT 5044
DATE VALUATION LOT TRACT
JOB SITEAPN
ADDRESS 7.9-fi" VIASM CIMU.
OWNER CONTRACTOR/DESIGNER/ENGINEER
ftA.NCF10 LA 00..IJ-13, CA1,111cak"M POOLS & SPAS
`n)00 VIA !iM CLARik -74-723 IOMOIUVE' #A
RALM DESERT CA 92260
(760)340-9000 CAL# 4367
USE OF PERMIT
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P400L 11") SPA, OMN
14,000.0€; .LS
. EN'TUNINT191.) CON 't'OV CONSTRUCHON'it'-
PLAN; CHFCY.'r7fi7,z
CONSMAVCMYN F1.216 10 -1 -MO-41 9-000
TV&XMAA.41',%''AL OL. 101-Q40421-000
PrOON, 101-606-4204AIO
PLUMBING FW_ - 1*1001, 101 -M -419-W0
SUR - 'TAY rAL CONfr5rMUC*VON AND PLAN CHECK
LESS PRE -PAID
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=10 V)
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$148,15
$0.00
TOTAI, PF,RM#*f VIERNMENOW I . $348.45
RECEIPT I DATE I BY' I DATE FINALED IINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Form & Footings
Ducts
Slab rade
Return Air
Steel
Combustion Air
Roofbeck
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
Findl
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
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:
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