0006-219 (RPL)CENSED CONTRACTOR DECLARATION
C
1. hereby Er penalty of perjury that I am licensed under provisions of
Chapter cing with Section 7000) of Division 3 of the Business and
Professiolkodb, and my License is in full force and effect.
License� I
- Lic. Class Exp. Date
656128 C53 10/11/2(
�b'aite Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a I
License Law for the following reason:
1,_as!6wner 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;toconstruct the project (Sec. 7044, Business & Professionals
)`1 am exempt under Section B&P.C. for this- reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under 'Penalty. of perjui*y 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 370Q of the Labor Code,, for the
performance of the work, for which this permit is issued.
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 & polic . y,no. are:
Carrier 'Policy No.
STA` M14D,
(This section need not be completed if t . he permit valuation is for, $100.00 or less).
I certify that in the performance of the work for which this permit is issued,
11 shdllj'6ot employ any person'in any manner so as to become subject to the
F workers compensation laws of.California, and agree" -that if. I should become
, subject to the workers� compensation p . rovisiohs of Section 3700 of't'he.Labor
'Code; I shall forthwith comply WiththoSe provisions.
pate: Applicant
Warning: Failure to Secure Workers' Cornpe - n 1! sati on coverage'is uniawful.and
Shall subjectan e,mployerto.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 -Ccidd, interest and attorney's fees
IMPORTANT ,Application is hereby made to'thb'Director . of Bu . ilding 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 for inspection purposes.
ignature (6066066nt) ��-'�a�_'Date,ems'
BUILDING PERMIT PERMIT#
0006-219
/DI'TE
VALUATION LOT TRACT
S17, .60 -
JOB' SITE
ADDRESS 78-865 VTA N"TANA
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
T.D. DE8MTDE1VaX)Pb"r
CAIJFORKLA. POOLS &BWAS .
P.O. BOX 1736
74-725 JOKI DRIVF, -#A
LA, QUWTA CA 92253
PALM.DF9M,' CA 92260
(760)340-9000 CB110 355
USE OF PERMIT
Pool, AM/OF. SPA
POOL &- SPA ONLY- A.LARUMBARJUER-S SHALL BE IN PLACE AT
PR&PLAVER IN19PECTION, BLOCK WALL FOR POOL EQUIPMENT
ENCLOSURE. IS NOT INCLUDED IN THIS PERMIT
VALUATION 17,300.09 US
Wrn"T= COS 0K9M17CM0N
'TOFC
PI, m mECK Pu 1,01-000-439-318t:),�-:, 1122,85
�N
CONSTRUCTION ME 101-00"19-000.1, sigg.00
MECHANICAL FEE -- POOL 101.000-421!,,000 S21100
nECTR' ICAL FXE. •. POOL, 101-000-420-000 E $45.00
PLUMBING FEE:_ POOL
M1
2,
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rows.
SUB 'f O(I-AL C ON911 RLTC11014 AM) PLAW CTWCX
x PIZE-PAID 14=
so, 0,61
mrAmpim-m—IT-1- m mEnOw
RECEIPT-
DATE
DAT �, FINLED
INSPEKCOR,
O
1W
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
-- BUILDING APPROVALS
MECHANICAL APPROVALS
acks
ts
Underground Ducts
& Footings
Ducts
b Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
l . Ue/
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
_ 4V
Gas Piping
Gas Test
Appliances
Final
f
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: