RPL (0212-011)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury -that I am licensed under provisions of
Chapler 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
ti. r, .L9, r e z.
31,
C 24
Date) ""�t s Siof Contractor .fir ZeC—
gnature :.
OWNER-BUILDER`D.ECLAFIATION
I hereby affirm under penalty of perjury that Iam 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.
((4,, - ave 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. 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 provlsions.
?Sate 12 P, Applicant_
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall.subject an employer to cn'm�lnaI penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for.. a permit subject to' the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application•is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
i Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance.of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for insfp"egction�ppurposes. }
Signature (Owner/Agent) ; if 1�t f Ott 1C �.' Date LL
BUILDING PERMIT PERMI�I�
DATEs 'e //�s F VALUATION �g�Yp�9 ° LOT TRACT
JOB SITE
ADDRESS '�;�e^aii deWlrsE7��T�k.o
APN „w
OWNER
CONTRACTOR/DESIGNER/EN INEER
WAM01 ) P0013 AND PAS
79.500 MSSI.ON DRIVE EAS
ME
CA 9225 30
P'I III -A 110MIl C` k 9.221:E
CHI,# .415f3
USE O�a�+,F PERMIT
pp��- rr^��-�9g
1"001 AND VLt
i
PCI(YUS'P.A. M.:f1041Si'e3AMEI2S S1i."�1,a. ]BE I$+: PIAC:Z AT PRE-PLAS'F.ER
IMPECTION> RQUIPMENT WC"LJRTRE, NOT INCLUDED
Y)Vf il.I..C:NAw>IOR 40PA 30,= 00 U ,
FI . QED C04T GF CONSIRuCTION
30JAX:.0
FLAN CHECK M11; -A 01 �000,r439.318
CONSTRUCTION s`t'd.:, 1011000-118-00.0 y3�4,�td
P. EC>HANICAlr KE — POOL 101-000-421 -000 S24,00
T-'.i,.ECT 1C.&L trt? — POOL 107-000-420-000 �a1.OQ
1' �L'ta`�AfTI'3() F'TL? ;.. POOL
DEC 06 2002
CITY OF LA QUINTA
FINANCE DEPT.
Ky f f
.,-1`0TAi `CCM. .T)C 150R.f AIM 'P LAXCr:�1~iR�.nCXi7 f" '
S165�.43
RECEIPT DATE}, /� y t BY DATE FINALED Q INSPECT
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
t5
Equipment Location
Underground Electric
— 3
Underground Plbg. Test
Final
Gas Piping
�, _ ___5
PLUMBING APPROVALS
Gas Test
Electric Final
• 3 --Z
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
_
Gas Piping
Gas Test
Appliances
Final
s�
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:
t
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JOB ADDPIESS�C�J►t !33 CA �1�-253_, PERMIT NUM9ER OWNEN t- �R BUILDER�—MIDob- �? 5
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on this job. Any rd+anpos to this Iles must be spFroved by the Bulltilnp DWslon pdor to commencement of work. F will re I In stnpPape of waft and/or the voldance.
of. buidi� enmit. For each s Ecable trade, all inforrrlartic-n requested below must he ao lattld (rant. "dn Flle' le riot an able re nae. CIM
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FROM :J GRAHAM FAX NO. :7603217646, Dec. 02 2002 01:04PM P2
FERDER RESIDENCE RAISED BOND BEAM AT +18" KTH
CONCRETE CAP, TILED FACE AND
07a-500 MISSION DRIVE Two SPILLINS AATERFEATURES
So EAST
`MY OF LA WINTA. RAISED SPA Al
CONCRETE CAF
13UILDING~ AFEUY DEPT. SPILLWAYS
I r1 M v
1�-�. I. 1 i u � � 1 �
I , }
0
MINE
wr
.e" IllUlll N 11111W +ly
STONE AT NIAT@QLINE
AND ALL YmRrzr%L ♦I�'
FAGC'9
1_/111 FOOL
N Z/ 0EA6H FWOLE
FINISH
O 3h511 /
exr,an suCTICN
\ / AUTOMATIC
POOL GLSAN�i
\I SIGH • BF?ILN _ r
TANMN5
5HELF YV
WORELL.A
%ceve
0 w F a LWA 'A'
WILL BE CHARGED IF THE APPROVE
NOOK PLANS AND JOB CARE ARE NOT 0
THE SITE "FOR A SCHEDULE
INSPECTION.
.NO EXCLP !LY i
1�
MASTER
BEDROOM
—_11
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