0309-248 (RPL)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
C53 F;9.0 G21 1013112(
Date !� r Signature of Contractor ,• �+"�'� - "Iwe"
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.
) I -have and will maintain workers' compensation insurance, as required by
Mtion 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 STAT: COPAPENS.# TJ Policy No. 046-6168.2003
(This section need not be completed if the permit valuation is for $1.00.00 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 p;Pyisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: e+ Applicant ! _ i
f -AJ - O�P#�
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 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 fpr I spection ZV
J
Signature (Owner/Agent) Y; x tDated%"
"BUILDING PERMIT
DATE VALUATION 'T1<t7yvarOM LOT
PERMIT #
0309.248
TRACT
JOB SITE ADDRESS 'M-700 L�Is'1�'U.513i�,�%. APN r
OWNER CONTRACTOR / DESIGNER / EN (NEER
31219-AWO CA.1..I%072NIA F001Z & 9P (MP M -#W CO
?8.700 NAPIMI DRIVE X36-1170 AVRN UT, 54
IAQ•E5LLIT A, CA. 92253 lCoAnI13Lu Ch 92236
`Y60)396-9222 CBL4 00355
USE OF PERMIT
POOL I XD/OR :SPA.
1'OWSP,A, ALARMS/VAILI I
PRF -PLASTER llbVECT.ION
POOL MIDJOR 3fi�
ni
17,000.00 La
1'O
ArISIMMM (1109.17 OF CONSTRU(7110M
PLAN (:lil•CK FXE. 1(tlat 00.439-318 $117.00
CONSTRUCTION FZZ 101-000-418-000 $180.60
MECHANICAL FEIN -- POOL 1.01-000-421-000 00.421-000 $24.00
Fi..ZCTRICAI, VEE — POOL 101-000-120-000 8415.00
PLUMBING VEK -- Pool, 101.000.419.000 $27.00
I
SEp 2 5 2003 101
OF LA QUINTA
RECEIPT I DATE I BY
y 7NtgM
L. 11 PI i. -PAID FRS $0.00
S .9.31 `0
J
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS I MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
FireDlace P.L.
I Grills
Exterior Lath
Drvwall - Int. Lath
BLOCKWALL APPROVALS
Fans 8 Controls
Condensate Lines
Final
Steel
POOLS - SPAS
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location s
Underaround Electric
PLUMBING APPROVALS
I Plumbing Top Out
� `Shower Pans
' wer Lateral
Sewer Connection
Gas Piping
Gas Test
Utility Notice (Gas)
ELECTRICAL APPROVALS
Tem). Power Pole
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
OX for Finish Plaster
Pool Cover
COMMENTS: