0206-090 (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 'a
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6.56128. C53 111 8 M31/.2t
AhDate �` '`�" � Signature of Contractor - A ' ,v'
. .
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).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
Q ' • WORKER'S COMPENSATION DECLARATION
pCL 2
2 1 hereby affirm under penalty of perjury one of the following declarations:
LO � O :( ),"1 have and will: maintain a certificate of consent to self -insure for workers'
X W �= compensation, as.provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work. for which this permit is issued.
m Q U .(�P. I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of therLabor Code, for the performance of the work for which this
M F- . permit is issued. My workers' compensation insurance carrier & policy no. are:.
� z -`Carrier .;j3ATE, CO*XtI�1P?±PeU:f TI Policy No. 046006166.01
ob �" . a.
J (This section need not be completed if the permit valuation is for $100.00 or less).
f. Oj I
Certify that In the performance of the work for which this permit is issued,
rd shO not employ ny person in any manner so as to become subject to the
workers, compensation laws of California, and agree that if I should become
subtect;to the workers' compensation provisions of Section 3700 of the Labor
Code 1.shall foithwith comply with hose provisions.
Date / `4 ��, Applicant %- i
:;-Warning:. Failure to secure Workers' Compemtation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up tb $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706 • t-
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 forthl on his
application. ;
fi
1. Each person upon whose behalf this application is made & each person at
h d f h b f't k' .4 d d tt
w ose request an or w ose ene I wor Is pe orme un er or,pursuan • o
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 arid -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 caripellation.
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 (Owner/Agent) '' �-� � Date �
PERMITN
BUILDING PERMIT
DATE VALUATION�y3ti LOT 1tf� '" TRACT
JOB SITE ADDRESS 49-M VI.�MA EFFR�..I LA
APN S
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CALTF( ��,'�t'IAPOOLS 44. M'Aw (000 UNN' C O
R0, I3fis S 1716
25 a?i Sm� wvt#A
LA. QUINT : CA =9US3
PALM::'i.8FX A 92260
('iap4l-90(10 CI LS 0C3S5
-
USE OF PERMIT
FOGUSPA, 136Q.A-1 S)Z21-a4.199S: 6 f:.? ti' f11:CCr ArAL..rv"1',IY
TSS IN RACE PRIOR TO
r MIPLATMA 1113sPECTIaO. POOL ZQ1JT:'PDAEHT BMW. SURZ 140;
POOL ARDIOR SPA � 19Afhf al U
/
NSWIDIIATRI) COST OF COMMUC171011
PLAN: CHRCM FEE ?-Q1,-4; 9-318 1134. IS
CONSTRUCTIC44 WE 101-000-418-000 007.00
MECHANICAL FE-- PCDO 101 -000-421 X000 $24.0;1
T1 "ERICAsE..ls'IZZ P00t, ii11-000-20-.000
FLUM'9FNAWE-- POO -1, 1101 -OW -419.000 5127.00
JUNi 3 2001
`l:. r ("C�X+1 7.�%TC°iT� cif '� C;C 2':
$437 55
cgy OF LAQUI A 1;1•ES PPR-PAW.FRE S
$0.00
rFINANCEDEPT.
WEAL Pt 1 �'XTS DIC�?:1��31�
S437.��
RECEIPT
DATE
BY
DATE FINALED
INSPE
�T11
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS r
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 8 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 . Z 0 - z
Underground Electric
Underground Plbg. Test - 2
Final
Gas Piping -_ 5 - z
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
_
Encapsulation
Gas Piping
Gas Test
Appliances
Final /2 - Z
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)