0311-165, 0311-237 (RPL)U)
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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
495843 C53 �Iiir3lfOd
Date Signature of Contracto'"'�? -•
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 Sianature 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.
;�iA7� FU-ND,1CW24b
(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 sodas to become subject to the
workers' compensation laws of California, and agree that if I should become
Subject to the workers' compensation provision of Section 3700 of the Labor
:Code, I shall forthwith comply with those provisions. /
- /
Date: Applicant 1 f if - it i -�� - f ''t
I .
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
-A 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. j
Signature (Owner/Agent)�� Jt�' t ! (' 1 Date ft r r % � a
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PERMIT #
BUILDING_ PERMIT
y._
DATE / .'� 1,x VALUATION _ LOT 0311465 TRACT
JOB SITE
ADDRESS
APN
43-M-1 co KrE vn, C 1RO
-
OWNER
CONTRACTOR/DESIGNER/EN (NEER
GOSPER L13APif3ZaAII
kilIRE AGE POOLS
43-683 COX1 , DEL ORO
71 434 MWOW FtI ROW01
Lli CZLiiAlTfa CA 92253
LAIMFSACeti 91941
(61jGE,O-911 CF31 �f
USE OF PERMIT
1>001, .t f lk SPA
PfJ%7U.`.rPA..AL ARN2:iftiA.RIRISRS Si1A L HK IN PLACE AT PRL -PLA: TE...
Ipd87'�C?It31L T;QtrIPI�i�Nfi �N�s;�tiltLNC�T �Ni�l.ula�v
P001, AND10k SMA 39.000.00 I's
"r.".V'.t�h'IA'L' D 01041—'' 10F C':'0I49:I^ U It' N
34,0M.00
PIM CHECK FRE 101-000-4359-3 18 $201.83
CONSTRUCTION FEE 101-000.418.060 $310.30
VIEC}iM41CALFEL --POOL 101.000-421-000 $24,00
EIY..0 TPJC;AL FEE ...POUT. 101-000-420-000 $01utf
PJ1VM 91N(3 ).?KF; -- Pool., 104.000.419.000 MOO
Q p
0NOV
19 2003
CITY OF LA QWNTA
..Pdk) PLA C1W� `rC.lt
$608.33
1VO l AL .TD!.`rR RV I .S JUNIS D E BOW
133
RECEIPT
DATE, j `l
BY /
DATE FINALED —TIINSPECTOR
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
0. 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
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 I
Gas Piping
;`. PLUMBING APPROVALS
ast
Gas Elect cFinal
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
Final
'Utility Notice (Gas)
t 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)
COMMENTS:
NOTES:
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BUIL)ING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
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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 E/zp. Date
518742 C-53
r �
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:
( ) 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 fog 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
Sction 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 aTATL, FU1gD Policy No. 13782,50-2003
(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,Aosetf rovisions. I r
Date.'_ Applicant" �t.1��14 a ]I ,,7i�-�•
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
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 purp(oses. /
I Signature (Owner/Agent) ,jl I -'i Date
BUILDING PERMIT PERMIT#
0311-237
DATE11/24 VALUATION COD. LOT TRACT
,20CADDRESS
4 *-6W COk2 L a�' 'M 01 O JOB SITE
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
GOVER L01f0NACO
11MY MAN POOL CONMUCTION
43.683 COR.TE DFL URC)
111
LA QIMITA CA 92253
PALM DM'RT CA 92255 -IS
(760)340.2588 C`•BL44
1104
USE OF PERMIT
POOH. AND/OR SPA.
SUP.PLEMENTAI, TO PERMIT A (1311- 165 REF1.,FWTTHG CHANOZ OF
CO TRA.MOR
E IMMA,dcIV) CO IX, OF CO.ltiib".CRU(IT, ON
0M
SUADdARY
.
5UM1: ENTAL 1'f!;RtA PEE 101-000-423.000 $4.50ItNOV*
II
2 4 U
CITY OF LA Uula'tA
FINANCE DEPT.
SIUB-'I OD L COF3'MUCITJON A14D MAN C1WX_
`24.50
. ES3 PRE -PILAU) Fl 'M)
$0,00
•�ta�rA.�, �1�P �'� i1cs� NCYW
��,id,�
RECEIPT
DATE ry )
BY DAT FINA D
INSP CTOR
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
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
POOLS - SPAS
BLOCKWALL APPROVALS
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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS: ; °:
-
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)
M