0308-167 (RPL)LICENSED CONTRACTOR DECLARATION
Cl) I hereby affirm under penalty of perjury that I am licensed under provisions of
f- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04
W Professionals Code, and my License is in full force and effect.
0 =) ch License # Lic. Class Exp. Date
LLJ
r6�5.-228 C5.4HiC.0 }� ?/-ACo Z � Date � _ Signature of Contractor � •
J U C:) OWNER -BUILDER DECLARATION t
W w I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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 am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O CV
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FL Q WORKER'S COMPENSATION DECLARATION
C:) cc I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
Q (�)dl-have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
t1 H permit is issued. My workers' compensation insurance carrier & policy no. are:
�? Z Carrier STATF COMPFWATI Policy No. 046-6168-2003
cb Z)
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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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thou e provisions.
Date: "nk - Applicant—.4//1— �r
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 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 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 ffoofiinspection purposes.
Signature (Owner/Agent) A Date
ay -
BUILDING PERMIT PERMIT#
DATE - VALUATION LOT TRACT
JOB SITE
a'�i
ADDRESS ` . �>S t3�
APN r y
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TOLLEiROW. 0018 WC
CALXORMA.POOLS & SPAS (;TOP I,r" C01
7 3•-2 2 11iM WARING #300
a6-100 AVENUE 54
PAW .DESU? T C'.A. 92260
C OAC HELLA CA 92236
(760)398.9222 C-BL9 00355
USE OF PERMIT
POO.., A WOR SPA,
P0OUSP.A,,BHQ(A,?73I Z21.53 -1991x, IFIREPIT(496 AGAL,) 10 L.P.
a` F3WCK WALL, CITY STANDARD AL.ARKTBAraT7. ERS Sf ALL --L BE 1N
PL.ALP. AT PRE—PLASTER rNSPECTION.
4 .FT. WALL 14.0011F
P0_ OL ANDIOP SPA 13,840.00 Ls
F T>iXV A,rED CM, OF CC'rNSM-WI ON
19,000.00
PKRAU C' FEE SU7A ARY
PLAN CHH—CK FEE 101-000439-31,8 $128,79
C.ONS'I'IaUCTION PER 101-000.1418-000 $198.00
MECHANICAL FEE --POOL 101.000.4.21.000 524.00
` ECTP1CA1, FITZ •• POOL 101-I100420.000 $45.00
FLUMBINOITEE • .POOL 10I-000.4194000 $77.040
MM -TOTAL CG»NMUCT 011AW) PLAN MEC K
$422.70
LESS FRE -PAID WIE!3
$0,00
rui r�®W
$422��
0�f3mur
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AU
A M3
CJ- .' OF LA C'U!tI`IA
Flt;''"vicE DEPT.
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RECEIPT
DATE
10
BY f ` r
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VE EIN E Z1 rSP
TOR
1
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
POOLS - SPAS
steel q�—J
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
i
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: