0104-118 (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# } �c LSSic. Class jj Exp. Date
rt�r
Dated (' Signature of Contractor 4 t'
OWNER -BUILDER DECLARATION N
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).
() I am exempt under Section B&RC. 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
'Wc"tion 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' compensatipp provisions of Section 3700 of the Labor
Code, I hall forthwith comply with th se provisions] B t[
Dater t V Applicant P 'ell w -- 4" 1 / Y� `?�
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.
1IMPORTANT Application is liereby made, to the Director of Building and Safety
Lfor 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 fot inspectionjpurpposes
'�,�
Signature (Owner/Agent),Date_ �� ��
V"
BUILDING PERMIT PERMIT#
,
/
DATE j VALUATION _�, LOT BB�3�`I�x TRACT
JOB SITE `
ADDRESS
•-'795 VISA i9W.f:��.i�.�rr.A
�APN
,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1y:
C ,A. ' POOLS �pip�: S &...�'-.
MW C
� ' .P COT
73`..€ ♦♦. {Ep' yC
j+S
A,ijR�Y��
74?
;€,A Q'C.'s1 trvA, € A, 922.
'PALIA DIESUT CA 9226
(m)340'.9000
355
USE OF PERMIT
y�i 0, v.rS.trP,MKA.. SPA,
�l�k�r`P�'�..�.�'�'9?it.1'.hip;3'�.C[i01'�".'P�.'%UR.,E�iLIIF3i},4if<�'i'dC�kN�S11Si.�.i�07`Sr'«`��.•+
.
1
JGIR RJLnd.CvtA.il�,h�' �Y+.!CiA \J%' L+\lS157�01{.0.�'i.4d.J.9id�
+k•T71�S,74i'uldC7 ,
FIM CHECK M2030
VION.�;<'P:tK- i'lON ME M9.40
-7 POOL�17AA .00
��ya9p.F�.pC(�M�Yd?�y�/�iCpA1.^�Fpft� Q1({��1-fC7)fj�0-42{1aQ�(t1��0
U�GOY'/1�T[49V�I.�ils/ii"liri'°YMP.S.�.b .f 4J1^lA�b10�2i,�4/l9iII �'7JeiAt] -
.Y
P1AC1MM110 RE •.. Pool, 101.000-419.000 Mao '
MR -Ir ?1 AT., 4° x,.8,34TmuC ''f.w Amp t; ium
$554.10 '
LEWS PAR -PAID RUM
Ulm
' IT7:f'A FERMU F 901)'UE NOW
&-55,, 4a
RECEIPT
DATE'`
BY
DATE FINALED
INSPECTOR
tiro i s✓�'-1
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
Set Backs
Footings
Bond Beam
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
_
_ `G
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
_
_
_
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
d
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)