0010-136 (RPL)LICENSED CONTRACTOR DECLARATION ,
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
Professionals Code,•and my License is in full force and effect.-
License # - Lic. Class Exp. Date
X43 t f'2�-9
Date Signature of°Contractor
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 (Seca 7044, Business A Professionals
Code).
t
O I am exempt under Section ;'6&P.&Jor this,reason
Date'" Signature of Owner {
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of.'the. following; declarations:
O I have and Will maintain a certificate of consent to, self -insure for workers'
compensation,':as provided' for by Section 3700 :of the, Labd('Code, for the
performance of the work for which this permit•is issued.,'..:
( ) 1 have and •will ,:maintain workers' compensation : insurance,, as required by
Section 3700 of the.Labor Code, for the 'performance of the work for whlch'this
permit is issued. My 'Workers"- compensation' insurance -carrier &' policy • no. are:
Carrier . Policy No.' . .
S�atfTA,•71(TFdD• ' .129-00 uwnCUn A.iW
(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 permit1s issued;
I shallriot employ any person in .any manner 1. so as to' bedome-subject 6 '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; l.shall forthwith comply with, se,provisions.. 1. i
Date' Applicant
Warr ing:.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 comperisaiion,'damages as-
--- for in Section'3706
of the Labor.Code, interest and attorney's fees t
IMPORTANT. Application is hereby made to the Director of Building and Safety
for, a. .permit subject to the conditions'and ;'restrictions set” forth 1n his
application••
' 1: Each person'Upon whose behalf this application Is made & each person at
whose request and whose benefit work is performed under or pursuant to
-any permitissued as a res alt of this applicator agrees to; & shall,.indemnify
'& hold harmless the City.of La Quints, its officers, agents and employees:
2. Any permit issued -as a result of this, application becomes'riull and void if
work isnot commenced within 1'80 days from date of issuance of: such
permit, or cessationof work for 180 days Wlll,subject permit to'cancellatlon'
I certify that) 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'forinspection purposes.:--'.
Signature (Owner/Agent)' Date
PERMIT #
BUILDING: PERMIT -
<,
DATE VALUATION LOT, 6`010 —46 TRACT
JOB SITE .' _ - •
APN -
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
U .17
NATU`t M. EF`FIDI TS
EDMOYM14
CA 92.260
(-760)568a6726 yd ti:
USE OF PERMIT
;100LD/OAR SPA -
POOL &SP. M1?,CKI;'N(9J.,.Q1NV!5Wi1Ai6 AJ.A:PWSII%+iikigd2K; 1�1
PLNOIAX t?RE PL;<lSTEIR .114SPID(a i0k POOL, r4UI MZ14 f` EHC3 t?1tr: E0
NOT fNCLIYOPD fN TIM PLP.g1aIT.
POOL ANWOR, SPA 06. L8.
P:RW111M.'MWMAR,
'PLANNBCRE 03 y��q q t�. t p aro gyp
f.0US`i RUC" 'btSN 'FEE: j : � 101-0(3C" I R-000 �YYYf�,Cd3
ELECTWCA,L, FSE y.: POOL .:• : l 0). -0-00-4.20-000
,
Iai.UMBI 10 3r''h :.; POOL ' ° 101 $009419�0100
90"P.-TOTM,(TiWf°R
:00
U-33 P:PXPAWFJZ M!
Go
K., W-11 Ir"18 ITY1112 NOW
RECEIPT
DATE :..
BY { DATE FINALED
INSPECTOR
s
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Footings
Electric Bond
Main Drain
Approval to Cover
_
12_
Bond Beam
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
.01
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
COMMENTS:
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)