0010-218 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby.affsm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Pro%ssionals`Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6561213 1.53 10131/21
!
Date -Signature of Contractor t
OWNER -BUILDER DECLARATION`
f 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).
( ). 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:
Cartier � ' 1.Policy No.
STATE FUND
(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 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 tLpse provisions..
Date: /6,'n 44. r , Applicant—
Warning:
pplicant 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
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 f
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/'
BUILDING PERMIT PERM T#
DATE qVAWATION»r 5 LOT - TRACT
JOB SITt
APN
ADDRESS r<
48-'.$0 VISTA CAMCM
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
K% T30X l 716
74^0/25 JONX L1:RiVE, #A
(760)340-9000 C'B's`A 353
USE OF PERMIT
rROMJNDICA SPA
PLlZ1R.I1OEC ION,'COLF-00fPMVNT EXCURSUR111 18140T NCLUDIYO
IN THIS
Pool,ANDJO.'FLAPA Ls
PAMMIT PKE, SUAWARY
CONS T.RUC1`ION .RP, 101-000418-000 $171.00
a
Z121IL" Tilri:.&L FX : ••a POOL FU7 ^�?t7D~d�Q1-d�Cti � � �dd5.f1FP
aoiF i3lga 1+*' ,. ff'CL't L 101,0m)-419-000 $227,00
:�.
AID
OCT
2 3 2000
Jhy
LA QUINT
IPLA14 C'WR
•'f{ I -TOTAL CCi fa3TI}UC:Tx+:1.N AM:)
I ifi 'i :5 .
RECEIPT
DATE
BY' 1r
DAT FINALED
INSPECT
J,
Z
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
Footings
Electric Bond
Main Drain
_
Bond Beam
Approval to Cover
s
e
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
Gas Test
�•.
PLUMBING APPROVALS
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)