0103-227 (RPL)LICENSED CONTRACTOR DECLARATION
1 -hereby affirm under.penalty of perjury.that I am licensed under provisions of
Chapter 9 (commencing with Secilon 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Signature of Contractor '���• �p�� `'
OWNER -BUILDER DECLARATION
I hereby affirm unde-r 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 contractingwith diceped
contractors to construct the project (Sec. 7044, Business &dProfessionals
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.
( ) 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 Policy No.
2TATP. FUND 3�,1�a7'd•01
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance ofjthe 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 thosefprovisions.
Date: •.2, ., *I± 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 as
for a permit subject to the conditions and restrictions set forth on Eris
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 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"fgr inspection purposes.
Signature (Owner/Agent")
BUILDING PERMIT PERMIT#
DATE. f VALUATION LOT �35�.-'�i' TRACT
,,-2f to , �Z
JOB §ITE It
APN
ADDRESS MOXWON0 GLORY
OWNER 3
CONTRACTOR / DESIGNER / EN INEER
7.9-190MOR-Imal GLORY
661 El UGEM17 RD,
LAI Qlm %, CA 92253
PA1.. RI)�«�,. IGS CA. 922,64
(760)32:7^7592 ' OBLO, 886
USE OF PERMIT
1k00' ,ANWOR SPA
PCIO dSPA. ALA►PMSlk3Aititll RS SHALL 8E.01 PLACE AT E'R.!=.-PLA.S'?; M
R49PEMON. M6 EQNJ1 M1~'NT RHOLOSt RY, NOT INCLiMPM,
POOL AN D10. R SFr
.��Wt1J.d 7i,il'1.1,A.. �'C.i,ZV:ldVx«t',M4�4
.
-PLAN CHECK TK
r0NST'ft lC'T1CXN 391: 101.000-418-000 $446.00
MF,MIANICAL, FEF •- POOL 101-000-421-000 $24-.00
BLCc::TR1U L P89 y- POOL 1011.00117-420-000 $43.00.
PLUMONG "Me, POOL 101-OM419-000
anIq
.ed JD1ta0.90
MAR 2 9 20(a J� r, PISS VIDt. N,0
CITY OF LA OUINTA
FINANCE DEPT
�
RECEI�`
"
DATE L�^� f
BY I
DATE FINALED
INSPECTOR
/ %
i{/J
�
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
nsulation
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
a
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Sewer Connection
Pool Cover
Encapsulation�,—
_
Gas Piping
Gas Test
Appliances
Final
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
Utility Notice (Perm)
Mar 23 01 09:22a' WORLD DESIGN
w:.
760-674•-0813<9 p.. 2
A RE -INS PE -C l:.ON FEE OF x$30.
WILL BE CHARGED IF THE APPROVED
.. _PLANS AND JOB CARD ARE NOT ON
THE SITE -FOR A SCHEDULED
yINSPECTION.
NO EXCEPTIONS!^
d
GATTUSO POOL CORPORATION
667 EUGENE RD.
PALM SPRINGS, CA 92264
OFC (760) 327-7592 FAX (760) 778-4920
LICENSE # 672850
I
CITY OF LA QUINT
BUILDING & SAFETY DEP .
APPROVE �
FOR CONSTRUCTION
DATE BY_r4,1, t