0108-115 (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 # ILie. Class Exp. Date
��Gl ��� C�:j3; .F�i;G•�v^� � f' �'y,�7E h �r ani
Date � & Signature of Contractor
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).
O
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
Section3700 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).
O 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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with thoserovlslons. fes,
Date: aT Applicant {` 7,
Warning: Failure to secure Workers' Compensation coverage Is Unlawful and
Shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's. fees.
IMPORTANT Application is hereby.made to the Director of Building and. Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to'
any permit issued as a result of this applicaton agrees to, & shall, indemnify,,,
& hold liarmless the City of La Quinta, its officers, agents and employees:.
2. Any permit issued as a result of this application becomes null. and void if:•
work is not commenced within .180 days from date of issuance cf such
permit,.or cessation of work for 180 days will subject permit to cancellation:.:'
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby` authorize representatives of this City to enter Upon.F
the'above-mentioned property for inspection purposes. T
X
Signature (Owner/Agent) ✓ % �" Date r - +�� ••
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE •`�" "' APN
ADDRESS Vspa y
OWNER �ad�t�'A CONTRACTOR / DESIGNER / EN (NEER
TID. I,Jl,'.aRT:Isiw9��C:r.:.titPWI,M
RO; VDX) 41.6
LA. 11. r,A ah x'215:;
USE OF PERMIT
74725 JONI 3XUVY, ;3UAA
MIA DESERIT :CA 92260
POOLAMMOR &A
PCxk,1USP-AA>rQ,ANSS.Z21-59.100. Ai.,A:3tNISIHkRbciM Sti<.PtUf:,,K, n4
PLACE AT PFtEPd.ANS"I'M NOPECTIO14, 'PbOt ittiUtPMENT ENCIMiJl.Lr,
TTOT 114,cwoza
P0014 ANDIOR SPA, is
�yyy gqppuugg �{ , �yp� 01MUA R9 r°01n'rQ "
A A"$VIBX•Yy ,�J .�.�� �W.IYAA�I•WrR
PLAN C�r�F.4:t� M19 101-000-439-M 5161.180'
Cd 3!8;T.R CTXCIM FEE 102-000-41'8-000
hi;frMAXIC L RM --.POOL 101-000-421-000 �a�.t3t►
XL¢CTRYCA-t.PEP, .POOL, 101„400r426006
PLUMBING F91t -- POOL 101.000-419,,000 $27.00
AUG 13 2002
LA
AND KAI ME=,
L"_11 11.3 FmIl" HMINI
I I RECEIPT DATE :I BY DATE FINALED I INSPECTOR
$511.60
.00
4" 1M
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 Wail 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
t
Equipment Location
Underground Electric
Final
Underground Plbg. Test
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
— �T
Gas Test
Appliances
Final
COMMENTS:
11 II
Final
Utility Notice (Gas)
t ELECTRICAL APPROVALS
Temp. ,ower Pole
Undery.ound 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)