0005-221 (RPL)LICENSED CONTRACTOR DECLARATION
iereby affiirrri under penalty of perjury that I am licensed under provisions of
iapter 9 (commencing with Section 7000) of Division 3 of the Business and
'ofessionals Code, and my License is in full force and effect. A
License # Lic. Class----Ekp^Date
ate
�1181`
, Signature of Contractor
OWNER -BUILDER DECLARATION. '•
v
I hereby affirm under,penalty of perjury that I.am exempt from the Contractor's
License Law for the following reason:
—( ) 1, 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
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:
Cartier ST�.TE FUND Policy No. 1034903-99
(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;Californa, and agreg that°if I'should become
suJaj"ect t� 'e workers'Scomperisatiionrprof�Isions of�Sectior{t370- of the Labor
ode, ha �o/ h�!th complywiththo e /o5isions. �r,
Date: f V 11
"Applicant
-...
Warning: Failure to secure Workers' Compensation coverag .is�U)nlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his .
application.
1. Each person upon whose behalf this application is made & each person at•,
whose request and for whose benefit work is performed under or pursuant to.r
any permit issued as a result of this applicator agrees to, & shall, indemnify
& hold harmless the City of La Ctuinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days ffom;date of issuance of such
permit, or cessation of work for 180 days will sub1ect permit to cancellation.
I certify that I have read this applidatibn.and state teat/the above information is
correct. I agree to comply, ith.all City, and State,Jaws relating to the building
construction, and. hereby authorize representatives of this City.,to ent r upo
the above-mentioned property for inspection urposses.
ignature (Owner/Agent)�'`j Dated W
BUILDING -PERMIT PERMIT#
DATE' VALUATION LOT. TRACT
(N.' 2?l3X'& d,2100.00
JOB SITE
APN
ADDRESS Qi4-wix A D f:
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Uk WMTIY. C -1101b ,
AMMUCAtT POOL CCiMTRUC11OU
44.430 VXL rADR1A1E
73960 N.. 011WAY 113
1A 42t1;NTA CA 92233
PAUM lj1r=T CA 92255-'! t
(763;1340-:25'38 CBVI 1104
-
USE OF PERMIT
POOL MWOR VA '
FOOL &SPA ONLY-AI.A1E, S1BARP ZRS SHALL BE IN PLACE AT
I'43&PLASTER INSPE+CTION;POOL F4UIPiVIWf A-.NCLOWRK NOT ITI:":LUDED
IN THIS PERY11T.
POOL AND/OR SPA 21LO00.00 1A
1:;ffi`$'i�AA.%'�W C0s1' of Cidi�i�.[�2.T1'C'now,
t,f1f?i).17
�9p
PJS�f+AL.LYB. , 8JW. SUMMARY ..
PLAN CHECK FEE 101.000.439-318 $140.40
CONSTRUCTION FZZ 101-000-419-0000 221.6.00
ME, CHANICAL FEE -•• POOL 101.0004421.000 $24.60
ELEGY. iCA.L. IEEE — POOI, • 101-000-420-000 $45.00
PLUM)3D40 FIX.-- - POOL 101-000.41moo W,de
M`
0�
4
SL1MWAL CCeATMMTMa.9 KM PLAN CT1.RICK
$412.40
LLSS PRE-PAMMO
$0.00
6 1—m. Iq
S452.400
;fY
RECEIPT
DATE
B
DATE NALED607
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
y
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
SD
Underground Plbg. Test
Final
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
,2 0
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)
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