0010-133 (RPL)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty ofperjury that | am licensed under provisions of
Chapter 8kmmmominO With Section Division ofthe Business and
,s� |oCode, and myucenoo/ommnmnmand effect. '
uo��/uoo Exp. Date,.
.. .
Date of
`
OWNER -BUILDER DECLARATION
' affirm under / of perjury that |omexempt from the Contractor's
License Law for the following reason:
( ) ' |, as owns of the property, or my employees with wages as their mole
compensation, will do the work, and the structure ionot intended nroffered for
sale (Sec. 7044. Business mProfessionals Coun).
(. ) |, as,bwner of the property, am exclusively contracting with licensed
contractorcontractorsm construct the project (Sec. 7044. Business m Professionals
Code). . �
Ulomoxam�unuaGonmm�a&�o`fxmm�aoon.�_�____�_
bate'`—Signature cxOwner
' W��R��n'����PEN�AT�N��
�L���T�m. . .
| hereby affirm under pona|ty'of perjury one of the following declarations:
()| have and will maintain acertificate u,consent mself-insure for workers'
oomponoaUon, as provided for by Soonon.3700 of the Labor
' �m
Code, ,o
performance of the work for wmoh this po,mitioissued.
.
( ) | have and Will maintain workers' compensation insurance, oarequired by
Section 37000xthe Labor Code, for the performance ofthe work for which this
permit i� issued. mywm,mas' compensation insurance carrier & policy no. are:
Carrier Policy No. �
(This Section need not be completed if the permit valuation iofor $100.00o,less).
( ) | certify that inthe performance o,the work for which this permit ioissued,
| shall not employ any person in any manner so as to become subject mthe
workers' compensation laws o(California, and agree that if| ahuu|Uu000mo
ou�ootmthe workers' compensation provisions o, Section n7oOo/,mo Labor
CvUo, I shall forthwith complywith those provisions.
Date: Applicant.—--',
Warning:'Failure to secure Workers' Compensation coverageio unlawfuland
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
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 employe6s:
2. Any permit. issued as a result of this application becomes null and vbid 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 Date&
BUILDING PERMIT
DATE VALUATION LOT. TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER EN61NEER
(760)340-90010, CVB14i 3 15
USE OF PERMIT
.P0101, A)IDIORSVA
POOL WAMR. SPA
PLAN Oftex DTZ 101-000439-318 $117,00
CO)MRIXTION ng 101 --000-41 StO,00 $140.00
WMAUNICAL TME — POOL, 101-000-4,21-000' 324,00
E1JP,-'—McAL &qg POOL 1,014000-420-000 941.00
IX31433 11RE-RAID FM
$0.00
-TSPECTOR
RECEIPT
DATE
By
DATE FINALED
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
0. 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 Wali 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
2_n
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas TestElectric
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
/� Z �• by ��'
Gas Piping
Gas Test
Appliances
Finale
4/
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)