0212-092 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licenced 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. b
License # Lic. Class Exp. Date
�i 6123 053 BIC� 0131122
b �rA.
bate.. �— 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).
( ) 1, 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:
(.) Lhave 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:
Policy No.
Carrier `T•�eT CO; PENS, 7.1 946f)Ot3ti9.�f;-Ua
(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' I compensation provisions of Section 0 of the Labor
Code, I shall forthwith comply with those • rovisions. ,
Date. 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 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 aut orize representatives of this City to enter- upon*,
the above-mentioned property for inspection purposes.
Signature Owner/A ent , =1, Date
BUILDING PERMIT ERMIT#
DATE - VALUATION - LOTTRACT t
11/13%200 91960 ,00 C
JOB SITE
APN
ADDRESS 49 .
OWNER
CONTRACTOR/DESIGNER/EN &NEER
P,0 ? 71. 1716
86-1.00 AMAE 54
LA QiJMA <,.A 92253
MA-MM.U.: ; t,"A 92236
C/60)398.9222 CM.0 00355
USE OF PERMIT
POOL ANDIUR VA
POOL.04iD SPA. 8I S.Q•,A'3S1 Z21.9.1995. I#Lfte1.M:SfR:9.fi}.tt�t'S SHAI L BE
W ,PLACER PlUOR TO '~'REPLASTFIR 114SPECTYC.1K P00L F QUJP1 r.NT
E2dC OSUIlt NOT TNC.1.,:'Jr3E0114 PEMT.
POOL AM= SNA Is
E67MA17-D COSI'OF 4° �6MM'tIC"9 ON'
29,000DO
'R id', ! 3. W 11ARY
PLA14 CHECK EY, 101-000-439-318
CON TRUCT1014M19 1011-00a418-000 Yf313.€lit
1►1WHANiCAL TOLE »> POOL 101.000-421.0010 SA00
F,LW- '1CICAL P H3 -- ;POOL. 101X000_4:20_000 $315.00
PL'JAIf9100 FEZ POOL 101.000 1.1.SUM $27100
a�sw,
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.: DEPT.
RECEIPT ,_
DATE f' %
BY (�
DATE FINAL
INSP
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
1
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
r
Footings
Main Drain
Bond Beam
Approval to Cover
— _Vy
Equipment Location
_
Underground Electric
y
Underground Plbg. Test
Final
Gas Piping
i
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
3a— -
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)