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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
/
656128 C53 .W0 44 �'j � j � Ula 1l�
Date !`Wu�� Signature of Contractor /• !//�'�""'I�"'
' or
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.
TATE COUPt?M ATI 046.063-204
(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 thosefprovisions. ,✓
Date: 1. 2 d `M �` Applicant—
Warning:
d, ..f ,✓'r ��t�
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 for inspeccttion purposes
Signature (Owner/Agent)""�' Date 4r Z)'��
NGPERMIT PERMIT#
DATE - VALUATION' LOT 0401-3M TRACT
JOB SITE'
APN
ADDRESS 49-40 DR]s'3ff C£7Y7kd"1;'
_ H
OWNER
CONTRACTOR/DESIGNER/EN (NEER
'CRAWS JrACf JKC
C `C..%OW4V,. FOUL S & SPAS (TOP;,IAN CC
9.968 I'IIf3EW ST 93, 1 Q2
Q6.100 AY'»7VE SSI
SAN t71T jt. (TO CA 92131
COACIT'LA CA 92236
(160)398.922.2 CHIR 00355
USE OF PERMIT
i 10al..Al,n-VOR q°A
P001+l PA..A.L.A.11bA5/8AU.RIXR,`; SF.iA:1.L RZ IN Cit &CF.AT Pfat'K-PLASTER
aNSPIMIri N. EQUIPMENT FMC.Lt SURE NGT INCLUM
rOC)1.ADlWOR. SPA 19oFi00,1t0 101)
17,0.00
PERMTr IV.V- Sid'; GA AaRY
PLAN CI.1MI X FILE 101-000-434.318 $111.00
CONSTRUCTION FEE 101-tt00-=1•IPI.010 $1$0,00
1V XCILANIC;At, ME -- POOL 101-000-421-000 $24,00
E1.ZC.TRIC.Al, YE : •• POOL 101.000-420.000 W.00
1'1.trtJ€1?1140 RE, --1'000 101-000.419000
i
JAN 3 0 2004
• r CITY OF LA QUINTA
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i*_T0T 'a�... bVl�i ►)dt . •.•.f• v - .• ate.
/�1�y +y /y�,
1�/ 93.00
$0.0ci
'Jr0TAJ*..PRRWT,11'.IKE8 DIM NOW
,
$393100
RECEIPT
DATE/ ;
By
DATE FINALED
INSPECT
(4411
-
RP
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
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
nrwati _ Int I nth
Final
BLOCKWALL APPROVALS
Set Backs
PLUMBING APPROVALS
Lines
jShower Pans
Sewer Lateral
Sewer Conne
Gas Piping
Gas Test
Final
I ELECTRICAL APPROVALS I
Temp. Power Pole
Low Voltage Widi
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
Temp. Use of Pat
Final
Utility Notice
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Iiijlif &3
POOLS - SPAS
-.27-_N