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LICENSED CONTRACTOR DECLARATION
+I hereby affJ'Gm under penalty of perjury that I am licensed under provisions of
Chaptew$ (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
Zate
Lic. Class Exp. Date
28 C53 ,� WINS
Sigpature of Contractor ' - "4
11
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
performanee of the work for which this permit is issued.
( ) 1have and will maintain workers' compensation insurance, as required by
4,$e t� ion 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:
Carrier Policy No.
3T.:3 fs FI;141)
o16 :%`. _tAXhi 1611
(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
Code, I shall forthwith comply with those; provisions.
Date:-!,,- ``?"i'Applicant t �`
Warning: Failure to secure Workers' C mpensation 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. 4�
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
instruction, and hereby authorize representatives of this City to enter upon
thelabove-mentioned property for inspection purposes.
1. X11
Signature (Owner/Agent) %��� Date`?'
BUILDING PERMIT PERMIT# CONTROL#
')8�3i-1�►3
DATE VALUATION S19.0 01) LOT TRACT 7202
441-
ITE
ADDRESS 80-240 RIVIERA JOBAPN
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
XSL LAND f',
CAt,Q[ ORNIA POOLS & SPAS
56-140 PGA BLVD,
74.725 JON1 DRIVE, HA
LA QUIK A CA 92253
PALM D SERI CA 92200
(760)340.("0 eft# 355
USE OF PERMIT
taiY)f.Atdf)OR RPA
►'taC�L �ti .`it�A rCJl/ty ['AlfV.i3fty, e A42i�]� +iie eLt2i Et 3 :3H'Ai i. Mi IN AT
t�K.t-fal.A.S`C[i}Z. tNfiPk;C:'t`It)1V,
0S T Ii1ILA.t E.D COST OF f 4XN,',*T.tti'1l%W)[. 0%N
PLAIN CHECK F147 Sl'I.8 All
(71OWNTRi fr"'L'FOIN T ga: 10,11 -000-41 R -f!!)(1 5 t 98 t 10
1tL"•t_1)t JK_'A,L IM -- POOL 101-000-421-000 SZ1,00
11h`i4-- f3001.. $45.01)
Pt.,tf19}it_T�if:. t.� h't? _- � 1�'tt, (f� 1-�'d3i? •d i !>-11t1f 3 T�;yT (>fl
-11Y1'Af>Ct:t_NS'P[tIY-710N AND PLAN C'fi1:i7R
5422 70
PASt1
LESS PRE -PAID PEES
100
JUL 2 81998 TOTAL 000, NOW
t5�7.z.i1i
ITY OF LA ry IINT'
RECEIPT
DATE 4
4,Y #*0
DATE FINALED
INSPECTOR
11"
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INSPECTION RECORD
OPERATION
DATE
INSPEdTOR
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
t
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
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
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
L
t
Final
Utillty Notice (Perm)