RPL (0312-050)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that.,l 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
656123 C53 MCI, 01cp 20l31�fk
Date `„ • v 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:
( ) 1,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:
Carver Policy No.
STATE COM PENSATI. (46-6103-.2003
(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 thoset provisions.
Date: Applicant
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 applicator agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildi
construction, and hereby authoriz�,Iepresentatives of this City to enter up
the above-mentioned property for,in pect'/on purposes.
Signature (Owner/Agent) / �C Date
ILDING PERMIT PERMIT#qq��
DATE VALUATION' ', LOT �+%�'"��rw TRACT
JOB SITE"
APN
ADDRESS
_,V-934,M.ie. SIGN D.lf.0.` E EAST
_ ..
OWNER
CONTRACTOR/DESIGNER/EN (NEER
I'1�1,w 7Wf %i�r �1.OS�A�I
C�TV�.St1TA4�!}C)T.S ,� VAS MAX CC
PO BOX 1716
.;"fiCsP
86-100 AVRIM 54
I..&fimrv. CA 92253
COAf';'HRU.A CA 92236
CM)398.9222 C;}a" 00355
USE OF PERMIT
POOL AIRWO . UPA
P00USRk 3ftQ ( 14St Zal .50N 119951 PIRF.?ty (4Q6A0ALy 6 J -P.
V BLOC' VIA.Lid CITY 31'AWD.P RD,.AL.ARMSro, AILRIERS SM LL BE fm
Pum Ar PIMPLASTEf7 M' PEC`.ION1
Ff. IML 6=" V
POOL: AIMIOR SPA 18 Eryt,.00 Ley
ESTMATELT CO.Sq M C0.1rTSM'C!'C'CCON
1911000"
PURMT1, IM_ .0 WYMMARY
PluM CEECIC FEE 101-0001.39.318 VV135
t";t 7NMIRUC TIOEd P'E"E. '101-0 30-4.18-000 $20100
MEC Ii QUCA1, FEE -- POOL 101-000-421-000 $24.00
ELECTR C'.AL VEF-% POOL 1101-000-420-000 $48.010
PLtt?44B1140 FEZ •- POOL 101.000.4.19.000 MA
u&-TMAL COMMUCrITION AND 1XLAN CRE
$437.MS
LESS 17RE-10AIi)MES
$0,M)
e
'DEC 0 8 2003
CITY OF LA MIINTA
FINAMCF r;! -:PT
LAIL 473
BY
DATE FINALED
17
INSPECTOR
1'1
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
steel
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
— Al
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
UtiCdy Notice (Perm)