RPL (0401-011)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 Arid
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6556128 C53 WCT ICi }'A1(VIIIca
Date'- Signature of Contractor � r �
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
performance of the work for which this permit is issued. r
(,ar)wl-have and will maintain workers' compensation insurance, as required by
'S don 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 STATE COfVdi'TiNS Ti Policy No. 0.46-6163-20041
(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 provis ons of Section 3700 of thel Labor
Code, I shall forthwith comply with those pro i'sions%
Date: e' % • Applicant .� /, ,/ , /�4
Warning: Failure to secure Workers' Compensation cover 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
whose request and for whose benefit work is performed under or pursuant to'.•
any permit issued as a result of thisrapplicaton agrees to,' & shall, indemnifyi,.
&.hold harmless the City of L•a'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. f
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 authorizeIrepresentatives of this City to enter upon
the above-mentioned property for'ins/pection purypoosse�s..�p
Signature (Owner/Agent) J,& 1l:Date
' B����� NO -PERM_ IT t PERMIT#
DATE VALUATION \;x ~ "LOT • TRACT
JOB SITE �.
ADDRESS
79-5974, SION D %3T P.A.W
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TD DUOR'l- DEVEJ,01WERIr
CALM OARINMA. POOLS SPM CI'OP MAN CC
PO BOX 1'716
€I6-100 A\+'�`MJR 54
LA QzMr:i A CA. 92,253
COACH&LA CA 92236
c'76T#398-9222 CBS 00355
USE OF PERMIT
POOL AND/Gyri VA
POOLIS.iA,11;aQ(AH3i L�1�5,3.1 1s"�, FiRVI P (496,AaAL), b L .K
.A' BIA)L"K WALI+,
PILACLAT Y?PF. PLAS`f'K:i THST>11CTION.
3 Ff. fICAI L 2,00 LF
P00f1 AND/O.fi SPA f.'1,327.00 3.�•
IC:+.DNfel.ii D COTE aF (';ONS" itxlt-MON
1910W_20
PERNU:i°FAT f•Inx&MARY
I'L*1 CHECK FEE 301-000-43,9-318
CO: STR.UC TIOIN IFEE 101-000-418-000
MECs'IMIC.t1L. `- POOL 101-000`•421-000 324,01)
ZLECT R11CAL FEE P001, 101-000-420-000 W.00
c''s.,UMBI3`7C3.F-619 -- POOL1;Ji.00(3>/!•jl9-000 $27.00
3CYI-��°C3T.I�+i. 4:C9ri.3` 1 .L.3'(%TJ0xNT J'kl-E) PJ_&.N+1' i."r.� ICK
$437.55
1 'jrAL FffTaV'T 17 A Dt1:p"
W7,55
JAN 12 2004
CITY OF LA CUINTA
FINANCE DEfl—
RECEIPT
DATE )
BY
DATE FINALED
INSPECTOR
'
I R 2 f , t
.,i-' ..t
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
• •
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
ry SJ
Gas Piping
Gas Test
Appliances
Final
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: