0012-184 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury. that I am licensed under, provisions of
_*apter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and`my License is in full force and effect. .
License If Lic. Class Exp. Date
MW895 03 04 13 VIC
Date' " �� a• `!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:
( •) , 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 & Professional's
Code). - ' .... .. .
O I am exempt under Section' B&P.C. for this reason,
Date Signature of rOwner
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 seif-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:
(V) I have and will maintain workers' compensation insurance, as required by
Section 3.700 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 Policy No.
STIOS FUND,
(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
Codej shall forthwith comply with those provisions:
�`Date:.k t., - t ' ` Applicant `
/'
F
Warning: Failure to secure Workers' Compensation coverage -is unlawful and
shall 'subject an employer to criminal penalties and civil -fines up to $100,000, in
addition to the cost of compensation,- damages .as provided for in to,
3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions , and -restrictions set forth on 'his
application. .
1. Each person -upon whose behalf.this application is made & each person at,
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this.applicaton agrees to, & shall, Indemnify
& hold harmless the. City of La Quinta, its officers, agents and employees.
2. Any permit issued as'a result of this' application -becomes null and void if
work is not commenced within 180 days from date of issuance: of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read -this application and state that the above information is
correct. I agree to comply with•all City; and State laws relating to the building
construction, and hereby authorize representatives of this City to enter'upon
the above-mentioned property for inspection purposes.
Signature • (Owner/Agent) Date,
PERMIT #
: BUILDING PERMIT
DATE VALUATION LOT' TRACT
JOB SITES f _ - . _ .. _ _
ADDRESS 36YAWw C&TJC;
F
OWNER
CONTRACTOR? DESIGNER / ENGINEER
TO DEMRT 3,wEiiEL67PNIFt) T . '..
C:s'4fi.WORMA POOLS A IWAIR
F0 BOX 1316
74.72a JOM AMME, #A'
La�t�1�OITA� CA 92253'
3�1�.t..�.�.ix,.wT".i�.$' C� 92260
760)340-,9000 1 11386
9
USE OF PERMIT
P ci0t.,,AND/i» SPA
POOL, & SA.&M•]�Q(.c WSlZ'1, 1'591 95) SHALL, 131
tw PLAN,T PRE mAsER marnp—° f'#OAi,!''t►0L EQL1IPUY4T R14oxx9',r11t
A. 'NOT INC1LU1736 W THIS f?LIMAl'i,'
I'001r,A?TMR. SPIN W90.0,64
PLAN CHTXK FEM 1101 -000-439-318
CONSTRUCTION M 101.000-418-000 $171.00
MKI IAAMCAL.1fRE -- POOL X101-000.4211.000 924,00
'
PLUMDT140nF : POOL €()lyr3ili3�4't��)i1 ��.ttif
®EC 2.1
liTi-Jl`S^ik.Jv.la°C�td
,P�'' «a.
TAL PiLiikt�.'71�I7" �1~► � N' AVO
n
'4 -
• _ -'gay
RECEIPT
DATE
BY 'me q-�YDATEFINALED
INSPE R
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 Hacks
Footings
Electric Bond
Main Drain
_
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
GaEles Te
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
..,
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)