0103-214 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date .
te
DaSignature of Contractor
iL ri g, A"44
OWNER -BUILDER DECLARATION
I hereby 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).
( ) I, as owner .of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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:
Cagier Policy No.
STATE FaM 046016168-00
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) -1 certify that in the performance of the work for which this permit is issued,
I shallznot employ any person in a .y 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 witKthose p��, ;I's/�i ns,/j�,
-"ate: Applicant �R�� .N
Warning: Failure'to secure Workers' Cornpe4ation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up•to $100 00
addition to the cost of compensation; damages as provided for in n 3706
of the Labor Code, interest and attorney's fees. (!
IMPORTANT Application is hereby made to the Director of Buildi Lafetyfor a permit subject to the conditions and restrictions set h application. 1. Each person upon whose behalf this application is made & e h perwhose request and for whose benefit work is performed under o purs
any permit issued as a result of this applicaton agrees to, & shi ll, indemnify CIT
& hold harmless the City of La Quinta, its officers, agents anc employees: F
2. Any permit issued as a result of this application becomes nu
work is not commenced within 180 days from date of issuanceof such
permit, or cessation of work for 180 days will subject permit to.cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all. City, and State laws relating to the building
construction, and hereby authorize representatives. of this City to enter upon
the above-mentioned property 'f$?! inspection purposes.
Signature (Owner/Agent) Date
BUI.LDING?ERMIT PERMIT#
DATE, _ VALUATION LOT 0103-214 TRACT
JOB SITE
APN
ADDRESS
OWNER
J
CONTRACTOR/DESIGNER/EN INEER
T.D. DMERT ` .
C"AUOPMA POOLS & SPAS
A`NI B(YX 1716
14-72.5 J_0X1'- }R1.V'1%' HA
(l,da 7s 9'1 aC°4F, y 92253
PALMDI£.S,'�°:,f r "CA. 92260
(76'Q)340.90 30 MA 1.386
USE OF PERMIT
POO IT MINOR VA
Pt`?OUSPA CDNY-41 Al A0VV49A9WTP:1 Z 5iI,&.E:t. 09 $fid PE -AC I?,A('
PRL •-:PI;o.ST&R. 04SPECTIOAL P001, EQ111PUEN In—I ".`f.,(:►861a; IEi NOS
IATC'.13t.)'F+M IN THIS PEI MIT.
POC)LMG4OR SPA WM9100 'tea
F,47m, IT YOZ SUMMARY
ivH CPNVK F-99 101 -000-439 -3 ♦ 6 312&70 70
Ca)WS'1Mt1UCTiC r.q PEP 101-.000-418-000 $199.06
M',C,9 K0JCiU, FEM • - POOL 101-000-421-000 $:4,00
1!,E.,`K 1U(,'A',LFEEw-P+OOL 101-049"120-000 $4100
2 9 2001_______SUB
`
ML C01,40TRUM1014 AM AM CTIRCIFE
1,q0-
OF LA DUINTA I. .4 PPMPAMFE D
00a
INANCE DEPT
TOTAL- FURL ;4' F MS DUE NOW
RECEIPT
DATE
By �" %
DATE 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
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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 1^low
Electric Final 1 _
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
. i 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)