9904-166 (RPL)LICENSED CONTRACTOR DECLARATION
1,hereby .affirm under penalty of,0erjury that I am licehsed under provisions of
C ' hapter"91 (commencihg With Section 7000) of Divisio'r�.3 of the Business' and
Pf,�fesSionals Code, and myticense'isin full force and effect.
Licen's'e # : ` %Lic. Class . Exp. Date
.9 8`19Kature of Contractor
�
OWNER -BUILDER DECLARATION•
I ir�6 affirm under penalty. of perjurythat I amfrom rom the Contractor's
License Law. for the following reason:
as owner. of,the.property, or my employees with w-ages. as their' sole
bom,pprisation,, will do the, work, and the . structure isnot intended oroffereld,'for
sale (Sec. 70 44, BU , siriess & Professionals Code).
owner
ofthe' propery, am" exclusivelycontracting
with licensed
contractors to-construkt`the project (Sec.:7044, Business &Professionals
%
exempt der Section
)A am�e t_ ' unB&P.C.'for this reason
Date - 'Signatu�re, of Owner'
WORKER'S COMPENSATION 'DECLARATION :
11*,hereby 'affirm bridef. penaltyof '-Rerjury,one of the, following declarations:
^1. have,ard will miainta-in'a ce'rtificat-e of"con'sent to self -insure for workers'
65mpensaiion, as:provided'for ,,by Section 3700,of'the Labor Code, for *the
performance of. tlieworlk forwhich this permit'is' issued.,
i:.
maintain d: by (x )','l have'and Will rn t�6 workeirs',comp - e6sati6n - insuianc as require'
Section 3700 'Of the1ab6 . r. Code, for* thelpeif6rman6e of . the 'work for which this
permitis issued My: insurance carrier & poHicy no: are'
Policy',No.
l(WIC07
41 N.SURANITCE"
(This section need riotbe4c6m'pleted if the p6rmitvaluation is for $1100.00-or']Igs):
.j'�i certify that in the performance of the work for which this permit is is�sued;
sha'll'- not employ any person in any. manner so as to be come subject to the
workers' rk4rs' compensation laws.of California, and agree,that if I should become
syb ect'tothe w6irkers compersaiio� provisions of Siction-3700 of the Labor
Code, f4Nilfforthw-i ij�th6oep`
-1 ith.comply rovisLqng.�.�..
I ,
Warn , !n Fail6re to secure ; . Woiee"r�; Compensation coverage is-unlA��fur�an d
Zar subject an'employ& t6 criminal penalties;a6d civil fines up to $100,000, in
addition to ihIJ cost of c8aipbnsation, daiIages as provided for in Se'&ioiri'3706
bf the,Lab6r Code, interest and attorneys .fees.+
161POAUNT, Applicationjs here�by,ma6 to'the 6rector of Building and Safety
n -s �4d .set f6rtli' n.'his
f9r, i,l permit §ubjedtAo'the conditio restrictions , 0
application.--,. T;
11.'Each 1p&6on upon wh&.se behalf this, app lic6tion is made & each persona
w ose..reqqest 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 issbed'as a result -of this ''application becomes. null and void if
work rk is- not commenced, within 180 days from -date of issuance of such
",permit, or. cessation'of work fdr'l 80 days will.subject permit to cancellation.
certify,that,l hav . e 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 her6by�authorize� representative's of this City to enter upon
the; a6ov'e- mentioned property for inspection.p0poses.
91 ySig lure.,(Owner/Agent) t r> a `— Date'19
PERMIT #
BUILDING PERMIT''
"04466
VALUATION $24),,n(to.4g) LOT TRACT
DATE vii"
JOB SITE
ADDRESS 77-15IS
014 V'
APN
-OWNER
CONTRACTOR DESIGNER ENGINEER
�.,TCINTYRZ.r-' P010)IS &Jq
a
;5_y920 i7wv Juiv,L)
P.O. 8 IX 170 1
LA QLANTA CA 92251
IA QUANTA CA., 92253
GFMA 1945
USE OF PERMIT
POOL iNDIOR SPA
COAMACIAI, PWI)SRA ONLNAARRIORS $11AU'as, Ilq PLACc A11-
(Coty w.
POOL MMAYRR313A
"? C0NLST,.,jLT!C ()N
C aNf 0?
ESTI'MATEM F1
ITIMITIFEENUAIMARV
PLAN CHECK FEE
00i'ROTRIUMMION FES '10!. -MO 418.00 $207.01).
W-CfLIVACAT, FU — FOOL $24.00
a L le 101-W`420-000 $45.00
POOL 101.000-40,-000 $27.00
RX
LESS f A"All) FEES'
TOTALRER MITI,' VC ESD U -C'NOW
RECEIPT
DATE
BY
I
DATE FINALED
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
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
- lie -
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
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)
COMMENTS:
-G
/ G