RPL (0210-085)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 # r Lic. Class Exp: Date
f}f t3't
0,53 Enc 1' 1 2,431:02,
Date tSignature of ContractorI'
OWNER -BUILDER DECLARATION ,,y
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for, the following reason: %,-e'
( ) -1 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).
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:.
Carrier tJy;'`}' Policy No.
(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: s.., .,. 4 Applicant
'o`
Warning: Failure to secure kWorkers' 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 Fi s
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 1 -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 property for inspeciion purposes.
6
Si nature (Owner/Agent)Date+•• 1 * ,
s- PERMIT# c
BUILDING PERMIT
DATE. ` j''
4
VALUATIONf rw- LOT TRACTJOB
' 4
SITE eol
ADDRESS,, , `«�>rp wo.cS��SItf 9+L�riz 1
APN ..� +',+C
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.At3AF SJUMO1,1S .
1XM4M.,1D OLeS AND SPAS
`yYaa�7y���,:1�'g{t%h*[f•�y'.yry(pqv;�q
..
LA, �,Lili,.Ndat'!. CA `9223.3
i).'L_1 !1:0Fi'3R1?.•J: � ? �c�A .'��22i1
USE OF PERMIT' 1
Po(111,11MWOR, SPA
POOL, SPA, WA,Nt`yltFA,.LL. AJ.-A.is.1f14SM.E:.iw,N.&MM'S `a'Ef kkt HE IN' PY.,t`iM.F3 T ;
D `
PR1; PLA' TfX 1H9P'>~ ,T10K EQUIP1!4ENT ),'NC1,09URF MO K INCLUDED
PtXXANTWOR SPA x0moo 4
EWINWILM 00S' OF CONiqTRB1'CTI 0 iF
30po Dm)
PLAN O'13ECK YKU, 101 -000,439-3 3 S $184,
CONSTRU '',ION 179t 101-000.410-000 5 t1
SiRL:twHA NICAL FEE, ••- POOL ' 101.000421.000 024,00
EU.'CTR_1CA.L PEP, „a POOL 101-000-420-000 $45.w
iLtTi+AB3WTYrr,F? - POOL 1016'000.419-000 $117.00
•i� ;lo3-M1. i,WiI2TCl70.��kND IN C
�365,43
MEPWER3
PERM'r FEES DWI' Now
$0,00.
OCT `i
OF f QuitVA
civ -p'
;�QT.
RE
DATEBY`
/''.•�,..
^" ' r
Via`+...._
DATE FINALED
� -•
INSPECTOR
.-+•'.�- :.
r�,'S %�
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
�y
_
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
_71
PLUMBING APPROVALS
Gas Test
_
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
15k ZA
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
Final
Utility Notice (Perm)
FROM H pr FAX NO. :7603217646 Oct. 07 2002.12:13PM P3
CITY OF to QUINIA..
BUILDING & SAFETY DEPT.
APPROVED
-,FO C NSTRU ON GOL I= COURSE
lw SMLOM WATERFALL AT +W"
DA BY' WITH TWO THREE SPILLWAYS,
&xLDF.. qs' TO Be 3ELEGTW
LAMD-04ZAMNO S,
OTOM AT W4TLFLMAND ALL VIRMAL
FA4LS
ee�r FEWU
• '�fe.
81�M
nOR
TAfWIN6
SPIMp vv ;
{R�A .
� Q t
o _ Ro .
'�. °R^"8 oft" LILAC aw-
�wre
7.
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,�. NOOIC
FAIN
6REAT
ROOM KITCHEN I
l(, CITY OF LA QU1NTA SUB-CONT!
�TOR LIS
JOB ADDRESS MI
PERT NUMMM OWNE 1 RA BUILDER_... v� �
This *orm shaU ba posted an the. lob with the.BuYnY Inanection CAW at AY tdntaa in a conaeicueuanlaca. Only parsons apbearing on this list or their employees are authorized to work
CD ori this Job. Any changes to this Ilat roust be approved by the Building Division prior to aommenoement of work. Fe�File
w I re It In s sae of work and/or the voidance
of buildingPermit. For each a Gcable trade, all Information requested below must be flour leted a llcant On�rwtsnee able re once.
IL Contractor state ContraoWe Usama atAoau oaH ImurarKra Clow 6 dnm a
Trade CtanMatlon
Company Name
Claas((Boe,ion.
(e.g. A. S. C -e)
I Mmtaa Number
Itutaxxl
Erut. Date
lodxala l
Carder Name
(e.0. State Fund. CalCoap)
Pdw Number
IF nnot Vadeei
6p. Date
(xx/xxlxxl
Wanes Number
porxa)
Exp. Date
I>v/xa/axl
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R0019Na IC4191 •,
SHEET METAL IC431
R ADRING IG151
GLAZING IC -170
INaULATICN IC -21
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