0006-163 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
Licenvt ti � •r? Lic. Class Exp. Date
V3:1412 CS3. f it �i 16ro/2(
r� r� Signature of Contractors`°
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: '
( ) 1, 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 STATE FU14D , Policy No. W_001: rA
(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' compensatlon'provlslons of Section 3700 of the Labor
C/de, I shall forthwith comply withuthose�provislons.
pate: 6," - r )166 O Applicant/ I (...: '(; 4 'e
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
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 Ouinta, 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
constr ction, and hereby authorize representatives of this City to enter upon
the ove-mentioned property/�for inspection purposes.
Sianature (Owner/Aaent) i' - r t`� Date
BUILDING PERMIT PERMIT#
✓ 0"-163
DATE VALUATION LOT TRACT
JOB SITE -
APN
A
ADDRESS i%• ,tea �a+ .r N.JSIXt� V• 7Y r
OWNER
CONTRACTOR/DESIGNER/EN INEER
NOMAS P1008 °
JUMFIZErE CONS]'RUC110
19.4.34 CATUE V T A 'i:)kT
74360 VMMIDO RD
7,A Q(3'.t�`A CA 92253
PAUA X37 I;ERr
CA 92260
(160)773.3293
0SIX
5302
USE OF PERMIT
POOL fiNIVOR SPA
K
POOL & SPA 084LY• AJ ARNI81 ARRI", S S ALL U'114 PLACE AT
PR&PLASTER WSPECTION, BLOCK WALLS FOA XQUIP.MENT ENCLOSUR9
NOT MCLUDZD 04 THIS PEI MIT
VALUATION 24,.fl9fl<!0 LS
r
n'1 u mcohn oir CCi.I muarrom
1.01000.00
PERM- ME N .
•PI.vW CHECK , .t ;(f�.(1�JUa4:i�'n31S $76.05
C:f;3MSTRUCTION FEE 101-000-418-000 .$1.17.00
MEMI)WICALME--POOL 101-000-421-000 $24 90
'mss
ELECTRICAL PFZ-POOL j01-Goo-420-wo
1PLUMi THO TUE.. POOL A01 -M-419-000 $27,66
t
s i -TJ
t' •-t
..:�e
cct''-�
f • 3 fir.
STIS-'.tMAL CONSIRUMON AND PL AM CMCK
S.)89.05
LESS PRF -PAW PETS
sn,00
A'
RECEIPT
DATE 11"B%
!
f
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I DATE I INSPECTOR
lw BUILDING APPROVALS
Set Backs
Form j & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Final
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Tema. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
Temp. Use of Pa
Final
Utility Notice (Per
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
�y
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric 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
Gas Piping
Encapsulation
Gas Test
Final
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Tema. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
Temp. Use of Pa
Final
Utility Notice (Per