RPL (0402-379)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am.licensed under provisions of
Chapter 9 (commencing with Section 7000) of 6wision-3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
5C61, 28 C53 MC/ n AY i?I6d
' �r1
Date')�9.t�I Signature of Contractor—
OWNER-BUILDER
ontractor 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 Sianature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury' one of the following. declarations:
t�o�y_) I have and will maintain a certificate of consent to self -insure for workers'-
`Tornpensation, 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 STATF COMPENSATI Policy No. 046-068.2004
(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: Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the. Director of Building and Safety
for- a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work"s;not commenced within 180 days from date -of,`issuance of such
11 permit, or"cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that'the above information is
correct. I agree to comply with all City, and State laws relating to'the-building
construction, and hereby authorize representatives of this City-to,'enter upon
the above-mentioned property for inspection purposes
Signature (Owner/Agenyt)!`./.'�64�---- Date r °' `�'�•
F
PERMIT PERMIT Jt
- _ *f�_1G
DATE VALUATION F .;.,,.,r LOT 0401.379 TRACT
4, r . e•� .� : i� .
JOB SITE
ADDRESS < .-
. 9-742 M7S}�1Oi`7 DRWR,ik&r.
f
APN
- -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
I'D 1)1�`i•:t��' �M3:.OYSV.t W
CXOORIS�POCILS & SPAS .;MP Iv.IrPH (,'OJ
PO DOX. 17115
Rhe 100 A4J.1 NUEE 54
LA QUINTA CA 92233
C OACIZIA Cal 92236
(760)398.9222 CDLO 00335
USE OF PERMIT
ft
SPA
17O0USPA, BBQ(A1e3; FIRM"IT W(W1AL)
,kiL1.SRNi'SMA:RRIF.0 TO BE IN PGAt'E,AT PRE -PLASTER INSPECTION,
P,Q.UIPMZNT LeNCLOSU ENOT IXCa.,i;rDED
POM .ANDf(JR STIA; 1$,ow." L3
MMU.119D (,'05T OF CONSIRUCIION
PLAN CHECK YEZ, 101.000-439 318 $122,81
0314STRUCTION YES 10 1 -000-4 18-000 $389.00
MECH"ICAL VEE ... POOL 101 _000L421-GgO $7.00
LLEC, TRICAL .PI&E – OOL 1 Ct 1-Cb00-Aad-OQG $4t5.Ufa
PLUMBING FEV, POOLr-t"n-Ma $27.40
I
t
u v 2004
CI F'1' of LA QUiNTA
FINANCE DEPT.
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XUB—:tUrAL 0,01MMLJC"710-M MM PLAN C,HE–K
$407415
!ASO T1PR-1-'Atti'!I'J PE -19S
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RECEIPT
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a -
BY }
DA E FINALED
INSPECTOR
W.'
INSPECTION RECORD
OPERATION I DATE I INSPECTOR OPERATION I DATE I 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 POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location 3- //- y
Underground Electric
Underground Plbg. Test
Final Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final --q —
Waste Lines Heater Final
Water Piping Plumbing Final
r,Plumbing Top Out Equipment Enclosure
Shower Pans O.K for Finish Plaster
Sewer Lateral Pool Cover
Skwer 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
Ufility Notice (Perm)