0010-234 (RPL)N
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LICENSED CONTRACTOR DECLARATION
IPrsby affirm under penalty of perjury that I am licensed under provisions of
619!$W 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect,
License # Lia Clas's' Exp. Date
a
xfir i ter;Da�el,Gs+��>S�gnatureof Contraet&, ,
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
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 MIND
(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,
1 shall not employ any person in any magnu so as to become subject to the
workers' compensation laws of Californp, ,and agree that if I should become
subject to the workers' compensation provisioqg o�e'tion 3700 of the Labor
Code, kshalffojhwith comply with4ose/provisions.
Date:f7) 11 -4u�4V Applicari-i '•l''
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?It
whose request and for whose benefit work is performed under or pursuant tof'
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 sucht,
permit, or cessation of work for 180 days will subject permit to cancellation:.
I certify that I have read this applicatidnsand state that the above information is
correct. I agree to comply,:with all City, and"State Jaws relating to the building
construction, and hereby authorize representatfiy.e of this City to enter upon
the above-mentioned property for% spection pt:(rp0ses.
Signature (O. nw er/Agent)��'�� � � Dat
BUILDING PERMIT PERMIT#
DATE/�11f Jf 4 VALUATION LOT W1(-2' TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
RXf rNW1,91 M, URI
142-5 fir, iM�T`" d�` 1'�Y DIUV,
S -*4990
USE OF PERMIT
POOL AAD/011 SPA
POOL &3)?'/.k 0111,'1t'-iUkLRMW- BAR :1ERS RlA14,111E M PI A,C Z Xf PRE
PAky.,: �c'�ER 11`9` PKTION.l�v' OL KQUI�'I EWE ENCLOSURE 18 NOT Cltf�LUDET)
POO.LAW D/t',R SRA AN0.001A
TW TAI�3,'S°. C,`OS'r OF e'taNYM€.i :AOR
:QC1XXIODD
17MrrVIN, 91TUY
PLAN C -HECK FRE 101-000-439-318 $76.09
4401vS'1RUC:'PION PZ -F1 101-000-418-0,00 $117,00
MM' 'H Fit`AL FEE — POOL 101 -000-421-000 S?V'I, 00
ELECTRICAL rSN.. •. POOL 101-000-420.000 $45.00
PL ISMO1{` 41 Pool., 101-000-419-000 00.419.000 S29 W
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0CT 2 6 2000 r - IFury%l :r�n� 8� v . 14 ow
V169.05
Uf'L UXUAN ' ". -
RECEIPT
DATE j
BYA ,rr� 4 �A•
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
OPERATION DATE INSPECTOR
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
steel_
POOLS - SPAS
�_� Ol
BLOCKWALL APPROVALS
Set Backs
Footings
Electric Bond
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
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�y
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)
FROM RJT_HOMES
WA
FAX N0. 7605646505 Oct. 23 2000 02:49PM P15
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