0005-114 (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
r.
ProfesW."als lode, and my License is in full force and effect..,
License # Lic. Class Exp. Date
,483498 B C53 124311?,C .
,Date cif°% Signature of Contracto ° %"
OWNER -BUILDER DECLARATION
I hereby affirm under.penaitq 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
WORKER'S 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 Section3700 of the Labor Code, for the
performance of the work for which this permit is issued.
?,( �)thave 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:
Cartier 't " . Policy No.
LE010N,114SU11AINC �'YL3-1'19-039 }
(This. section need not be completed if the permit valuation is for $100.00 or less).
O 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 those prov&signs.f /
Date:;//�Er Appl&cant ^'� t�:fi'(r.�'.s+-•�4/'.
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 t.he. 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 e r inspection purposes:
r1% 3.'J �,�L.(:- ""E✓t�C+'CiSJ"r+d
Signature (Owner/Agent) Date, - •�
PERMIT #
`(I BUILDING PERMIT
DATE/ LUATION LOT Qi3t>S 11.4 TRACT
V
.✓ff SYS.:00
JOB SITE
APN c `p
ADDRESS 78•- VSA. tJE.I`1TAHA.
r
OWNER
CONTRACTOR / DESIGNER / EN &NEER
NE1? l AAiiflU'x .ti `
PLMPOOLS AM C01491'RY.i'*v'IlON
PO BOX12040
PiO. BUe 1524
PALM. DE.SEMT CA 92.2460
PALM DESERT CA 92261
(750)568-4963 MIX 725
.r
USE OF PERMIT:' '
1�00L AND/OR SPS?
POOL .& SPA. OIV Y•ALARMS/.RA :,1;IW SHALL 11311. IN PLACE A`i.' PhZ'
PUTTER INSPECT :OK P1006 KA) IPMYNT Etdf;` O SU1?E NOT IMC:LUDED 114
THIS PERMIT.
POOL AND1OR SPA., us
ICSTJMATED COST OF CONYMUC'i' ON
Y 15,0W.00
PK04:WFRR9UiMARY.
PLA14 CHECK fiEI" 101'000-439.316 �1ti1.�0
CONSTRUC`DONFES 101-000-418-000
MECHANIC AL FEE — POOL 101=000-121-000 $24.00
YKIXCTRII AL FEE - POOL 101-000=420-600 $45.00
PLLIMBINO FEL -- POOL 101.000-419.000 327.00
�.• f`at
Hx
)TA 1,CONSTRUC HOW ArmPLM (;;M3f3.:10
USS 1'x$:��.•1?,�i I --D F=3
s
4�T'
OT.AJ< ff,R 1dv'��1 I' mis DUM 2 )
a0.^0ti
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Farms & 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 8 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
Underground Plbg. Test
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:
Fw _
FROM.. •: ' PURRFEd� POOLS&CONSTRUCT'I ON FAX NO'. NO' 7603609829''n 3 �.v� e May. '10 2000 08: 18AM P3
Ir
13-0
xg
.31
' ,�• � ��/•1 f � '�Y' I i I i •I - � •j 111' _ .j I '
a: I I ,I L $ j, I• i F
1 ' A t S �ECT�ON, FEE j�F 301
-
PRO ,
�Wi BE'C �D.IF;TN APAROylE01
PLA S, D Jo CA.
CARD RE NOT i ON : -
tH -S'iE #O0 A CHEOU ED;
RVS ION � � � �• ' •i
1 I
eb
It
i�, ,
�
F I r
d � i r - i � . ,• Iil � I, it
rMOM.