0402-069 (RPL)LICENSED CONTRACTOR DECLARATION
,I hereby affirm under penalty of perjtc-,y that I am licensed under provisions of
Chapter'9, (commencing with Section 1000) of Division 3 of the Business and
Professionals Code, and my License is imkill force and effect.
License # Lic. Class, Exp. Date
x r • J n "Ij}F r;
,Date ��Signature of Contractor LI f /tom}'+ %+
OWNER -BUILDER DECLARATION C�!
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
.License Law for the following reason:
( )� -1,-as owner of4the property, or my employees with wages as their sole
comensation, will do the work, and the structure isnot 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
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby o 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 Section 3700 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 & policy no. are:
Carrier UVSb&T-2 UID 361.131 Policy No.
(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 1 should become
subject to the workers' compensation provisions'of Section 3700 of the Labor
,Code, I -shall forthwith comply with those provisions.�/
Daterr�/._ f: Applicant
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. k
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/for inspection purposes.
Signature (Owner/Agent)'`� d �t �-�r•-` Date ' A /J
p T
BUILDING PERMIT a PERMIT#
0402
-Of
DATE • ` •02.*,6/2()C VALUATION a $400.00 LOT TRACT
JOB SITE
ADDRESS�:MI.eL�S(!
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
STEV 3.MCLAY3C3{Ual'?J
XF.1,v1BRM3D'f POOLS LAM W;A$
78-910 V2 AVEN'1'ANA
46880 M(Y=CAW CMM DRIVE .494
QUIkTrrA CA 922.53
11-TDIAN VM -J 5 CA 92210
(760)34.3.1376 CSV6699
USE OF PERMIT
POOL A14DIOR SPA
WATER IfE i URL N*9' TH'U'i'A ER DEPTH LESS THAN ISO.
F001., AND/OR SPA. 400.00 Ls
ESrMXTED'C00r OF C'v. A'i :ON
,
p Ci1L 103 c,000•439-31$_ 9911/5
*MrJJ.5'r'RUC770N FEK 291-000-4113-000 315.10.0
EIZ,CTCAL WE -- POOL, 101-00.0-420-000 45,G0 -,
* `=
F'l.tfl"P,a40Ott as POOL 101400-419-000 gr,06
F'.$ .0 6 2004
R , ' CITY OF�LA QUINTA
FINANCE DEPT. ?
t SUS -11 T..P& C0W3TRXT=0X AN PT J*T CI•f"WX
x t+ $196.7:5
Lmss Px r,,:P jD 1'.3r?S
d . , $0.00
TOTIAL A-10-Mitf i+ MS DUE NOW
i
$96,75
RECEIPT
DATE-2
BY--
DA E FINALED
INSPECTOR
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
PartyNali Insulation
Condensate Lines
Party )Nall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
—1 -~
Set Backs
Electric Bond
Footings
Main Drain
_
-
Bond Beam
Approval to Cover
Equipment Location.
Underground Electric
Underground Pibg, Test
Final
Gas Piping
` PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
i
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
—
7iinal
Utility Notice (Gas)
y -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: