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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
743'11 ,:'. /►�f7>: j �, 1 ]'�'�of4
Date ' ?-' Signature of Contracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury thatd.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
S ction 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:
Cartier S. T.Ai` E I• U111 j Policy No. )!iKT 4-q9
(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 complyw(thh these, drovisigns.
Date: '�� 1 Applicant I'
Warning: Failure to secure Workers ompensation Coverage is unlawful and
shall subject an employer to crimi .. 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 application 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 oVthis. City to enter upon
the above-mentioned property for jnsp ction pu se?.
Signature (Owner/Age t) �'' r+� Date S- ” I
PERMIT
BUILDING PERMIT
DATE VALUATION LOT TRACT
} �/
I y cry
JOB SITE /
ADDRESS 45-145rA' JkF I�"-9,
APN
.. .-
OWNER
CONTRACTOR / DESIGNER / EN INEER
DAM s?ala1q
JMP F-14WR -�, USIRS
45.445 r,:AR147I
4 5-26017A.L�i lU.1',..
Lh+QY711ti1`M CA 9122S3
WDY-1i CA 9?1ZG1.
(?60)347=8913 CB141 4996
USE OF PERMIT
1'0101. A.4 D/OTS. 3PA
KJOL..r'',ND SRA ONLY. A1.ARNSMARRIRTUS SH"L BE IN P1.,AC X PRIOR
TO PPNP3.h0t'.F9-, INSPECTION, P001, UJUIP>;uiEW CTtr*,0;4URrNOT
Ise CL.UDFLI IN PERMIT.
r`'C3t)I,1aND IOR SPA 14,9001 0 I.9
WI'17VgAM) COST OF C"ORSIT :UMION
14XI. M
ff 1✓'1iiA.i`k7i'K ' 6 11MMARY
i'I�l1'rd C`1'iL�:l; 1 his"" i (_t) _000.439-31 R
%{17+6Ni"ltil'L"'tiC.�N f'�C; 1�1..(,li�-+t 1.S -UGC► $I�„'•.0(�
MEC-.RAVICAL FFF. •- POOL 101-000.421.000
EU+CTRICAL, FE9 •., POOL 301 -OW -420-000 sr'.i.W
PUIM'1111140 F9F 101.000-410.000 371I.Wr
I. . . � OCT1 l�akd .Jtisl11) PLS- W C1'n'r'X
U3113 PRE -13 M)FIRM
$216 3.30
$
:T_
C00FLAQUM
FINANCEDEPT,
RECEIPT
DATE'
BY} Y
DAZ
INSPECTOR
t..1
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-Z19U.
Ducts
Slab Grade
Return Air
Steel
55 —
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
LSLOCKWALL APPROVALS
Steel
POOLS - SPAS
— Z
Set Backs
Electric Bond
-Z
Footings
Main Drain
_ L
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
42
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
bRures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
`
'MCCALLUM POOLS 7603477221
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
ov► S , LLM
p11
04/23/02 10:62pm P. 002
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