0403-269 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I`_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
wLO
419305F C27 C53 12131 icy,
Z r-- Date•_ ! rlL1 Signature of Contractor (rco 0
- '���•�-�'
O r/
J U � OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z_ ( ) 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).
Cl) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
CL Q WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 370& of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
ED Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O (-).
Section 3700 of the Labor Code, for the performance of the work for which this
Il 0)F— permit is issued. My workers' compensation insurance carrier & policy no. are:
v z Carrier IDITATE MID Policy No. 514360
Ob /5y
C3
J
(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. L V'n
Date: "/C tac{ Applicant `.iw.,.-..�.f��x .
r
,;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 withinA80 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. `
Signature (Owner/Agent) !'t3•K. �`� '=-7= Date / r ` o/ `
PERMIT#
BUILDING PERMIT
DATE - VALUATION $15pG,' LOT TRACT
JOB SITE
ADDRESS 79--�F'�0 ,COR�T�. I3�,OsLA
APN - »
OWNER
CONTRACTOR/DESIGNER/EN (NEER
1Zi�.[.R KE)l
DEMW JPAP—AMBW .POOLS & RPA
79-W CORS s E'.IA
1.0. CNT XEIIO_ 0MIS C"
LA 4;iMr. A CA -:IM53
FtAWC"11.0 MUZZAGE CA
%2210
C160)836-0368 CML#
TA10915
USE OF PERMIT
POOL.ANW/OIC SI'A
POOL, 101D S,P,AWONL i'. ALAFW, B rZRIX0 SMALL HE 124 PLACE 3'RJOR.
TO PR9PbA.ST% 0,48PEC ION,
POOL".DI R SPA, fl BONA L-13
E:'75ID&WED 00417 (ASP € (I)KY.MiMI C.E,IN
.1519MID0
Cy asy��;.�t•�, l��gg•�
A-�..N.'4.4bA.CA 1?j�•� N7 i�.1!0.6LY.i14ii. 8!
tri. N CHECK FF„I 101-000-439-318 fel 1733.39
COX -111 i.Ufr..� 01 1 FEF, 101-000-418-000 $162.00
MT?CHANIC LIFER 101.000,421-3130
.M C H AWCAL M12— POOL 101-000--421-000 $24.00
BIAECTRICAL FEE— P001s 101-000-420-000 $43,011
PB.;P'. M131NO FE .. P001, 101-000.419-000 $27.09
=-A, r, TS711TiG1'. 01Z AND PI K14 c".i�[F.aM
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U33 P1:Ea'P..r'4I!'s MeD
.30, 00
MAR 18 2004
�:. TAI.,.'C�.i+� Fizd�iTYt�S'SBUY NTO
$363110
C11 r w' ... %A" U i*K'sA
FINANCE DEPT.
v
RECEIPT
DATE
BY ��
IN PECTOR
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
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
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: