0102-145 (RPL)r LICENSED CONTRACTOR DECLARATION J . t
I hereby affirm under penalty of perjury that I am licensed under'prov&s&ons'of x
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my Licenseis in full force and effect.
License # Lic. Class Exp. Date
686895 C5
Date !> 1 Signature of Contractor
OWNER -BUILDER DECLARATION
`Iwhereby affirm under penalty 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 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:
CarrierPolicy No.
OTA_
E FU 94 D
(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,
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 t Oise provisions.
Date: Ag Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensa Ion 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 Ng
for a permit subject to the conditions and restrictions set forth on hist
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 applicatori 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
theabove-mentioned property,f8r inspection purposes.
Signature (Owner/Agent) A ,I Jo �' S4 ` ."" Date ✓'
�f4w q -
.4 BUILDING PERMIT PERMTk
DATE VALUATION LOT, TRACT
1174.10.14.10
JOB SITE
APN
ADDRESS
!8-27-4; VISTA CALICO
OWNER
CONTRACTOR/DESIGNER/EN &NEER
O BOX 1716
4-.725 JOH1 D111 i , 0,A
LA. MIT& CA 92253
'PALM DESIRr :CA 512260
5386
USE OF PERMIT
'POOL Hs�*il
Bit :114
(POOL 7QdIP SpJV.R
P001..ANY9;fOR SPA m,000.00 us,
r , WALI 14.00 %,Ir
ToWM/.'9,IX 111 U)Av.71 OF V.. tONSTR4.1.4,TI OJ.tl
4✓f r..0 6J
PLAN C RC 9 'f�'',�'t�
)JUXOTWIC..P L FEE -- POOL 101-000-420-000 945,00
PL1.iMt IRLI FF --i POOL 101 -pori -4-1 9.O. -A MOD
ro C:' i i Rq C°eioN YEP, I. r a O'C;`d4 00-418aCJW $262,00
s os.9.a
a lat e �' -P19LEj:CPUS
.
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RECEIPT
DATE
BYfi �,�
DATE FINALED
INSPECTOR
INSPECTION RECORD
F OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
t Set Backs
Underground Ducts
t Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
I Roof Deck
Exhaust Fans
0. K. to Wrap
F.A.U.
I Framing
Compressor
I Insulation
Vents
1. Fireplace P.L.
Grills
I Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
i Party Wall Firewall
I Exterior Lath
Drywall- Mt. Lath
i
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
steel
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
l /,
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
Encapsulation01
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)