0108-108 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that Lam 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
650128 C`h'i 1110 C $ t , 01 l 'If,
Date ( 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:
( ) 1, 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
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.
STATE Ci£?MPIDIRA'P1 0460+6164
(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 those provisions.
Date: t-2- 4'7--- *o Applicant 3;V•'
d C..•. 4 s
'Warning: --F iiure"to "secure Workers' Compen ation 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 op his
application.
t:
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
t 4kove-mentioned prope rty,for inspection purposes.
Signature (Owner/Agent) ` Date �� "r �d't✓�
BUILDING PERMIT PERMIT#•
DATE � VALUATION LOT TRACT
����
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
?P.. & M.R.O. WFIR
C,'A1AMR.LNM TOOW & SPAS 1,10P.WW C01
79-62813P014074725
J0A4.1 DRl�t , K MA
LA QUINTA CA SIMI
:1>,e't1.IA D-FROU CA 91260
(60)?40N90t1Q C KA 355
USE OF PERMIT
�r
0TfNR OP P.
t'
PO01.J3?A;€3Q.AW 14371- 59.199S1IT11iXA PIT496.AOAL.
AIARIIi.4f13.AFtiAMR3 SMU, 0K IN PLACE AT F=Ri?.i'L/1`STF11 !.{WYM110N. ,
101.,,x'. 8Tl 5 H1n_ I4 81X>Cf; WALL, CITY STANDARD.
MIX, 32,&10(1,11014'
5 i'T.11'3ALL 10.60 LF
Xt''TS"i IXID COST OF COKIYARUCrnoff
31,2 .6
PLAN Ct9ktt11T,C'�,Xss�FFY, 101-(100.4:��sa:y18 s1�il,;t0
fV
CiSv7A9S'f'15UCTIr.. N YEZ 101-0000-41.9-000 $2991.50
kAMOUNIC.AL rig-- POOL 101.000-421-0,00 MAIO
i'1d9X-"TRICAL Ffw'ir -- POOL, 101000-420.000 $45,00
P'i,Lf M111kW RX -- Pool 1,01-000-419-000 $27,00
12M PRE -PAW Fes.
$0100
A a '� � '1'!" 's 1 c'
!6m
AUG 13 2002
CITY OF LA QUINTA
1.1 FINANCE QEPT.
R rFoy;
DATE FI ,r w
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
60ILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I I
Underground Ducts
Forms & Footings I J
Ducts
Slab Grade I !
Return Air
Steel I I
Combustion Air
Roof Deck I
Exhaust Fans
O.K. to Wrap {
F.A.U.
Framing J?
Compressor
Insulation i i
Vents
Fireplace P.L. I ]
Grills
Fireplace T.O. ] I
Fans & Controls
Party Wall Insulation'' f
Condensate Lines
Party Wall Firewall I I '
Exterior Lath I I
Drywall - Int. Lath I I '
I I
1 I
I I
Final
Final ; I
POOLS
- SPAS
BLflCKWALL APPROVALS
Set Backs ! I
Footings I !
steel--
Electric Bond
Main Drain
�� �c
• _ '.. p ( ���
Bond Beam i I
Approval to Cover
I {
Equipment Location
] (
I i
Underground Electric
Underground Plbg. Test
Final I E
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I f
Heater Final
Water Piping J I
Plumbing Final
Plumbing Top Out I I
Equipment Enclosure
Shower Pans l l
O.K. for Finish Plaster
Sewer Lateral ) I
Pool Cover
Sewer Connection I I
Encapsulation
Gas Piping I I
Gas Test I I
AWances II
J (
Final
I
COMMENTS:
li
]i
Final i !
Utility Notice (Gas) I i
ELECTRICAL APPROVALS
Temp. Power Pole I i
Underground Conduit
Rough Wiring it
Low Voltage Wiring
Fixtures 11
Main Service I
Sub Panels J [
Exterior Receptacles
G.F.I. iI
Smoke Detectors I I
Temp. Use of Power
+I
!i
Final I i
Utility Notice (Perm)'