9801-128 (RPL)LICENSED CONTRACTOR DECLARATION
'U I hereby affirm under penalty of perjury that.l.am licensed under provisions of
I— SChapter 9 (commencing with Section 7000) of Division.3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O ch License # f ,-Lic. Class Exp. Date
LOi
r; ! i 187
o CD O Date l—r-Signature of Contractor
Pr
JI.— C) OWNER -BUILDER DECLARATION
LU W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a
fn License Law for the following reason:
r
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
OC\J
Z WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
r< O () 1 have and will maintairi a certificate of consent to self -insure for workers'
X W LL- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U (\) I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
13LO LO Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
00
C) STA fi FUND � �- - • ti j 1034303-97
J
(This section need not be completed`if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work fol which this permit is issued,
I shall not employ any person in any manner so aslto so subject to the
workers' compensation.lawsrof-California, and.aee h�t if I should become
subject to the workers'_;compensation`provisions of �etion 3700 of the Labor
Code I sh I fort �Ai{1'th comply with those�yprobssions.
i Date: Ir Applicant �"
Warning: Failure to secure -Workers' tompens'dion 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.
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 orr 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 tys, application becomes null and void if
work is not commenced Within 180 days/from date of issuance of such
permit, or ce`safion of work for 1.80 dlaay's will subject permit to cancellation.
I certify that 1 have read this applicat on//fllaf �d state that the above information is
• correct. I ag fee to comply with all Ctty� a' ld�Statte laws relating to the building
construction, and"h e'rebyvauthor'• e r presentatives of this City to enter upon
the above mentioned prop y fin t�ection'pu poses.
�tSignature (Owns % g"enfi� _ r `i '�� Date �_ "�✓
BUILDING PERMIT PERMIT#CONTTROOLL#
DATE VALUATION LOT ,080.1-1 TRACT 6 5
111 S16,600.00 V VVV
I JOB SITE `
APN
ADDRESS 79-2015VI CfORU
OWNER
CONTRACTOR/DESIGNER/ENGINEER
NIOSE'BROOK, MIKE
AMERICAN POOL CONSTRUCTION
79-205 "VICTORIA
68575 SAA FEURE RI).
s'
LA. QUW. TA CA 92253
CATHEDRAL. CrrY CA 92234
(760)32•2156 CBI.,# 1.1.04
USE OF PERMIT
Pon}
_ . CITY OF LA QUINTA �
'POOL cYi S'PA WITH'�.F 5' RCJ�O '!]2C7N F�CF
T
1998
POOL AMOR SPA. 16,600.00 Ls FINANCE DEPT
L.
4
Y
EST1t144:A'tEO COST OV CONSTRUC ION 16,600.0
PERMIT FEE SU14IN ARY
:PLAN CHECK .FFT'd 101-000439-318 $117.00
CONSTRUCTION FES 101-0004MODO $180,00
N C HANICA.L FEE -- POOL 61-000-4211000 S24.00
FLEC: YRIC s1. FE `--1001. 101-000-420-000 $45.00
PLUMBING FFR - PM, 101-000.419-000 $27.M
SUB -TOTAL CONSTRUCnON AND PLS CHECK $393.00
LESS PRE-PAJD VE VS $00)
T OTi'% PERMIT FEES DUE'NOW 5393.011
V.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
0
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
Y 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
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
�
Notice
ELECTRICAL APPROVALS I
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fcdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
T6mp. Use of Power
COMMENTS:
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