0007-129 (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 # Lic. Class Exp. Date
t55ti12Fs � C53 10/31/21
Date '' c Si nature of COntfaCtof'-
OWNER -BUILDER DECLARATION
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, a§ owner of the property, am excfu§iJely conteactih§ with lid( ih§6d
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Dates 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 ( ) 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:
Camer STATE 1Uk417 Policy No. 046-R0-0006168-00
:(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,
f shall not employ any person in any manner so as to become subject to the
.woykers' 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 those provisions.
},Date:. i �. Applicant
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��
cons uction, and hereby authorize representatives of this City to enter upon
thefabove-mentioned property for inspection purposes.
�S, gnature (Owner/Agent) _ �Date
:.;
6 BUILDING PERMIT PERMIT#
lW� x29
DAT. VALUATION LOT O TRACT
JOB SITE -
APN I
ADDRESS 7-92s w mmo
-OWNER
CONTRACTOR/DESIGNER/EN (NEER
CEYJTii]€ZY CROWFLL COi MUINMES
CAL ORNJAPOOLS & SPAS
)535 50, *7 S, EES T, 0200
74-725 JON1 DRIVE, #A
SAN 133,Te'1U A1"t1: IU0 CA, 92408
PAU4 DIGSFIRT CA 92260
(760)$40-9000 CB114 355
USE OF PERMIT
POOL. WJIOR SPA
POOL & $PA OWLY-ALARMSkSARR13RS SHALL, BE YN PLACE AT
PiMF"i.,,t STER INSPECTION. ANSI 221-531.905
V'ALU.AT101.1 11280.00 IIS
F.ST7 "MID COSH OF CORSTRaFUrfON
15,280.00
PERhff:i F12 SUMMARY �
PLA14 CHECK FEE; 101.000.439.318 s111,15
COWSTRUC IOW FEE 101-000-415-000 S171100
�
MECHANICAL FEE •- POOL 101-000.421.000 324.90
EL.ECTRICAL, PEE - POOL 1011 -000-420-00 i $45.00
PLUMBUNG FEE -POOL. 101--000.419a000 5,27,A6
t
t.
Y..
•
7
STUB TOTAL COhTSiT U1,_ 11'ON A.1.05 PLM a.W.CX.
$318.15
LESS PRE-PArD F=
S0.00
TOT'A`L, PEST IVES ME NOW
076,16
RECEIPT
DATE
B
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 ;s
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
/ojcs,� Cc`A
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Final
Underground Electric
Underground Plbg. Test
Gas Piping
_
— f�
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
Gas Piping'—
Pool Cover
Encapsulation
�y
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: