9808-169 (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
'
6-128 C53
Iii%3 i 3
V� '"-;Signatur
' e of Contractor—
OWNER-BUILDER
ontractor
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).
( 1,11,am exempt under Section B&P.C. for this reason
Late 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.
r' 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:
Carrier Policy No.
(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 provisiohs'of Section 3700 of the Labor
Code, I shall forthwith.comply with Those provlsionts.
Date:gpplicant
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. r
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.4 ree to comply with all City, and State laws relating to, he building
Zonstfuction, and hereby authorize1per presentatives of this City to enter upon
thirabove-mentioned property,for in ction purposes.
Signature (Owner/Agent)- ` Date `r +
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT 040X_ f 69 TRACT
�tll:f9; S �E3..s+t3ilA 7547
JOB SITE
ADDRESS 77-38, 08-Ut 11i;OSA
APN
- -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
%0l . �1`�.P ia�'i Ila
kL
f.�.�. ..l,.. i.i fi�l �� POOLS & f.?1��i1
55920 i,", A 11LVD
74-725 JONI DRIVE, UA
i.A Q1:J1IrTA CA 92253
PALM W`S1?ItT CA 9220
1,760)341-9000 CA1.0 355
USE OF PERMIT
POOL ANUOR SPA
POOL r1.tND SPA AND R130
P001. A.i�.13= VA. . 20.5000.00 LS
LST MIaA•SlE..D'l..a.rtAli' OF LO.NSTRUCTION
L<'/e��'1Yyy:t7YS
PERMITFU SUMMARY
ILANC t IRE CKLE1-, 10.1-000439-318 S1�iCt.40
f'i~J1tiN3TR1?'C'}'ION FEE 101-000-414-000
MECIIIANXAL FEE ...POOL 1:01-000-4'21-000
SWIRICAT. FES _. POOL 101-000-420-000 W00
PL'tJM6.1NO FLEE- -=.*P, 0 1. 101 -0041.9 -OW $L'7.OrJ
x
81EIM-TOTY0P74STRUCTIION.AND PLAN CHECK
$457-40
LESS 11?T-yAWFETES
.
10.00
�-� '1't:DTA. PEIRMIT4 EES ..€ UE NON%r
S4552.40
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 yJ70
Final
Gas Piping p //
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water PipEf;'
Plumbing -up Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation��
Gas Piping
Gas Test
Appliances
Final✓� f!
COMMENTS:
/*4 10110W 4 �.
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
l
I ,
Final
Utility Notice (Perm)