0012-142 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury,that I am licensed under provisions of
4. Chapter.9 (commencing with Section'7000) of Division 3 of the Business and,
Profe ;'1'-�ionals'Code, and my License is in full force and effect.
License# 1 •Lic. Class Exp. Date
C.53 EFIC
Date Signature of Contractor
OWNER -BUILDER DECLARATION ;
I hereby affirm under. penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(9-;),1 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 a~
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).
( j I am exempt under Section B&P.C. for•this reason
Date »• n, Signature of Owner r ) '.-
�:...}_ �i� y,�•il.. SMO
WORKER'S COMPENSATION DECLARATION
�r...I. hereby affirm under penalty 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 for by Section 3700 of the Labor Code, for the
performance_ of -the work for which this permit is issued.
(')"td 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 "A;: F . Policy No.
`;.t%'�'�:�'13; `i�'i�`l�IfJ 1'b9 �D��1 •L+2
(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 for which this permit is issued,
IPshall 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 tho// a provisions. w
A i 4
-� Date: �: ry .� Applicant- �.,."���r• ; T . ;�
- Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of, the Labor Code, interest and attorney's fees.
IMPORTANT Application'is hereby made to the Director of Building and Safety
fora permit subject to the conditions and restrictions set forth' on his
application.
1. Each, person upon whose behalf this application is made & each person,at
whose' request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, n, demnify
& hold harmless the City of La. Quinta, its officers, agents and employees.
2: Any permit issued as a •result of this application becomes null and void if
work is not commenced within 180 days from date of issuance, of such
..permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representative's of this City to enter upon
the above-mentioned property for inspection purposes.
;fSignature (Owner/Agent)'%, Date"•-
BUILDING. PERMIT PERMTp
DATE VALUATION LOT 2..�n TRACT'
,JOB SITE',
APN,
ADDRESS
+•r, 1..�*•.�Q7n'Y YIL.'4,�.#�S.rnl'7..S:iAti�/. Y'S',a
..
6WNER
CONTRACTOR / DESIGNER / EN INEER.
DAN F'aYffla ?.t�,�,
r US0 POOL PS..�l'.t+;f B)IS1•tr�, ilq'(,
9 1W. 7 •
1, y ...omps RD, -
I,A(It=mrA CA 92:25
.'r�'iUA'$'.k'.S.v.!`NCiS t'lk '92264 • y ,,
aria $16
USE OF PERMIT
P00LANMX;1'%: SPA
1.10(!1" s SRA. istNlr"i'':.A.LARM :#BAt?i'VPS S1E.dR.1.r;<„BX IN k'LAi.E AT P RIE
1,143PEt;. TIOXPOOL 9QL4PMF'HT 914C1.ti+3URZ IS NOT ttX(,• DC4'0 �3
'
4
POOL, Af.4.r4l)R SPA
X1S'"'[`Jtd.WA £ D Ev' 'Ie"r Ole rL'+C flurRTJMOH
PlC".RRYT6'g RKE Ruhv&my
P&°.&4 CHUCK FEE $1I1.15
1? 1.01-000-418-000 t173.OP
MW"HAV.1CAL FEE •- F-001:• 01-000-421-000 VA,00
E EC ,"RiC'AL ?Ler, .>. 3bz: L 101-000-4.20-000
P v MOW4110 FRE P0, I, 101 -000 -4.19 -ON SAW
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ate} Gi"3 Nff??;i i C9 ASW) PLANT _`HECK
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RECEIPT
DATEBY
DATE FINALED
INSPECTOR
'4 .
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Steel
Electric Bond
Main Drain
Bond Beam +
Approval to Cover
Equipment Location
Final
PLUMBING APPROVALS
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
_
) 9
2l
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)