RPL (0303-262)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 and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
301807 C53 MC 12/31l02
Date �-�� Signature of Contractor-_.- ._'- - •---� "
OWNER-BUILDER°DECLARATION
I hereby affirm under penalty of perjury that II 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.
I have and will maintain workers' compensation insurance, as required by
S' "o 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 TU14D Policy No. 160573-20D2
(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'kprovisions of Sectio 3700 of the Labor
Code„ I shall forthwith comply with those pro slons.
Applicant., •-_#A7 P
Warning: Failure to securB,Workers' Compensation coverage is unlawful and
shall subject an employer to criininal 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 *w
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 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 inspection purposes.
Signature (Owner/Ag �s• -�'t / Date
-BUILDING PERMIT PERM T#
DATE \ -VALUATION ' � LOT TRACT
JOB SITE
ADDRESS —!%�.rJ J ��r.Y�wad�iCn'i5a
APN —
OWNER
CONTRACTOR / DESIGNER / EN &NEER
DAM, MMYM✓Y
BILKWOM POOLS A13 &AS
r�
S 1.045 MIUMMEND MI IAC=1v.
77.700 9z r.171 K LD LJ�` QUIT s F
LA Qjl]NTA CA 9225', ,
MINI DUW CA 92211
(7riU1200�5s`Si CLf X158'
I �
USE OF PERMIT
POOL .i NDIOR. SPA
-
-i�
(l.y a7 tsy LSL11,,1�.fid' . t d:.t1.7 Y• y�. HL..fi.KidEd _' �Y AC.S'Ca7c eMY'Js^LL . .
114 1'LA-0:G.t4,J' PRE-PLAnTgR INSPECTION. EQUIPMrMT MG1.OSITRE 140T
IHC:?;tTDED
P001rANIY OR SPA, bg000,g0 LS
l
EISTBUI D C0911 OF OOM'iRU Mon
4Yl=.W
PURAWT FEE WMIKARY
PIAN CHECK YEE 101.000.439.318 s7.72",18
CONSTRUCTION FEE 101.-000.418-000 $s^.A9.30
A�-;I�.O1 1WIC.AL KE -- POOL 101-000-421.000 $24,00
EL;?. ,TR1CAL FEE, -- POOL 101-000-420-000 $45.00
FLUMBINO 1EI1? ••• POOL:- 101.000.419.000 M 00
R.M
�
rr.. UB -TOTAL CON3Ti`z3:C10'T ON :MM PLAN CM 'X
$612.68
LV93 PRE -FAQ M3
$0.00
PERRUT FEES DVE NOW
RECEIPT
DATE rr�I/
BY
DTE FINAD
INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Duds
Forms & Footings
Duds
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
POOLS - SPAS
Steel
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
- Utility Notice (Perm)
COMMENTS:
03-25-03 09:02 RECEIVED FROM:
l SIN PECT0 FEE OF $30
I:8E CPARGEP I fHE APPROVED
' AND 10B C ARE NOT ON
SCHEDULED
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0!QUINTA
,UILDINGA44FETY DEPT.
PPR uc IODN
FOR,�0 S ,
ATE5--a-Z-192- BY