0210-285 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under$enalty 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
656128 C5 k C .}N O��1fOm
r,Vo..1
Date w 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).
( ) 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
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.
VL<�j have and will maintain workers' compensation insurance, as required by
Se tion 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 T_&( OMpg-W Th--Policy-fVo.--- �S3ti G3-5��
(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' compensation provisions of Section 3700 of the Labor
o
Code I shall forthwith comply with th"'
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Date. 's—" Applicant— ArY
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 authorize representatives of this City to enter upon
the above-mentioned
propel
rope yy for Inspection purposes.
Signature (Owner Agent) `' Date l: R
e -
GPERMIT PERMIT#
U210-2;
:DATE LOT TRACT
E
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
`l`'OLL A1ROTIMO XMIC
CALiszOMMA POOLS VAS t'i OTP 144N CO.'
74-923 HMMY USI .EMV SUTYRZ-270
(1-6-100 AV;Ir ILAUR 54
PALUDEWTIM.r CA 92260
COACRKLLA CA 01,236
00355
USE OF PERMIT
PO>~?i.141VOR MIA
ti`I;3f,31:ySF,P.�23E:�t
M 5 LAr.,'B A T .it'RFrPI.Nnv T F4R 11'FSPECk'TI N. &QUI sle�EN'T T04CLOS�a S NOT
M% 'S,l, AN:WOR SPA 1 $,Q a 00 LS
s:0�i `—tom , ° S RUX-170 I
F'1.0i CHECK VU 101-000-43,9-318 $12135
CONSTRUC'[°t"C3'A1' ME 101 0100.418-0€ 0 $10.09
MECifMCAL1<RE —POOL 101-000-4211-000. S124.00
R1hWTRJCAi; PU .- POOL 101-000-420-000 $45.00
PUUM, DINC3 RU ^- POOL 101.000-419-000 $77.00
DL 3 PRX-P W JIM0
210100
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2802".�'�ht91".1'
CITY OF LAQUINTA7
FINANCEDEPT. '
14
RECEIPT
DATE
BY
DA AL
�3
INS COR
U.).
lk
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION,
DATE
INSPECTOR
BUILDING APPROVALS MECHANI6AL'APPROVALSf
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 POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Heater Final
gPlumbing Final
:Lines
p Out Equipment Enclosure
s O.K. for Finish Plaster
al Pool Cover
' newer Connection Encapsulation63
Gas Piping /ET
Gas Test
Appliances
Final / 3
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)