9912-113 (RPL)LICENSED CONTRACTOR DECLARATION
I hereb�&ffir7F under penalty of perju"ry that I am licensed under provisions of
C . - 1111V - I Division 3 o the Business and . . I
`haIpter (commencing with Section ,7000) of
Professionals Code, and my License is in full force and effect.
LicenseLic. Class Exp• Date
to/'! it2v(
date 'Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm underlpenalty of,perjury that I Am exempt, from the Contractor's
License Law for the following reason:
A, as owner of the propB4, 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 projject (Sec. 7044; 'Business ,& Professionals
Code).
O I am exempt under Section M B&RC1. for this reason
Date. Signature 'of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm, underpenalty.'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 f6r. by Section '3700 of. the 1abor Code;, for the
performance of the work forwhich this permit is issued.
('r); I have and will, maintain Zrkers- compensation Insurance, as required by
Section 3700 of the Laborbode, for,th-e performance of the work for which this
permit is issued. -My workers'.bompensation insurance carrier.& policy no. are;
CarrierPolicy'No.
ST A"17113, F. "IND
(This section need of be completed`if the perm'if valuation islor$100.00 or less.
I certify that in the p6rformdnce of,th.e wo.rk'for whi0 this permit is; issued,.'
I shall not employ any person in.any manner so as_ to.b6come subject.to the
Workers'X-comoerisatioh laws'of Californ'ia, `and:'ag'red that if I should become
subjec't to the workers' 'compensation provisions of Secii6n"3700.of the Labor
h
Code, I shalliforthwith comply with I(those'prov6on 1
,.Date: Applicaii
� pensationdov-erage is unlawful and
Warning, Failure to secure WorkerS�-C m
shall subject an. employer
TIployer to.crilminal penalties.6nd civil .fines 'up to $100"060;.in
addition to the cost of compensation, damages as proVideb, for in Section 3706
of thb Labor Code, interest and.attorhey's fees.
IMPORTANT Application is heie6y'-made to the Director of Building and Safety
fora permit subject
ct - to -.the conditions and *restrictions. Set forth \on., his
application.
1., Each person upon,whose behalf this . application is made & each person at
wf;ose requ'estand for whos6 benefit work is performed under or pursuant,to
any permit issued -is a- result of this applicator'agrees to, & shall, indemnify
& hold hark,es, s the .di
City of. La Q Uinta, its officers,*'agents and employees.
n . m .
2. Ay perit issued,as!a result o ' f.this application becomes.null and void if
work,isnot commenced within 160 days from date of issuance of such
"permit, or cessation of Work for, 180,dayg will subject Oermit'to cancellition.,
I certify that'l have read this applicati6n and state that the above information is
Correct4 agree to I comply with all City, and -State la I ws relating to the building
Construction, and hereby authorize •representatives of this City to enter upon
the above-mentioned property forinspection
(Owner/Agent). -;16 bate
is
PERMIT#
.
BUILDING PERMIT
It 4
yr
DATE_LOT TRACT
99VALUATION $14,0 N)
JOB SITE 773 -1 7 5 V. L k .7rPN
ADDRESS4 Vr N TkN�
OWNER
CONTRACTOR DESIGNER ENGINEER
D DESE, al'r DE VE L(YP MIENTY
CAIl F 0 PUN I A P 0 0 L S & S P AS'
.1"Po BOX 1716
74425 JONI DRIVE, #A
LA QU]Nrt'A - CA 92:253
PAGM DESERT CA'92260',
40-9WO
760)3, C B1
Z'
e*s i
USE OF PERMIT
PS OOL AN_D/0R PA
POOL AM/OR SPA .1.4,000 00 L$
PERIWIT PCE SUMMARY
[11 -AN CHECK-FUE
M -Cl, 4. P N I CA 1, 171 7K E, V 0 04
y -W
UXX TRJCAL -0004420-WO
PIAA411040 FEE POOL to -1-000. ,'i19 -00U
SUB-1W.M. CONSTRUGFION -AND PL CRECIX.
.4
-AIN
.1 .E$S PRE NAM FEES
TOTAT, PlEltKIT VECS DUE IN1W
Jw"
A
RECEIPT
DATE
13Y
FINALED,
JINSPECT
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
Steel
POOLS - SPAS
Set Backs
Electric Bond
.�
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
G�+/
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
U Gtj
Gas Piping
Gas Test
Appliances
Final
Q/
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:
,