0303-079 (RPL)LICENSED CONTRACTOR DECLARATION`.
I h�-, reby 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
800650 C-53. }kl,, 1 Dl 1 p
Date d fy/ Signature of Contractor/% I 1� yie1.
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 f'liMF3'-N%L SU131 Policy No.
(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 withd1lose provisions
.Date: i% l/>/f`� Applicant—J
1i'toa'ar�,'�
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 applicator 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 a�b,•ove-mentioned propertylor inspection purposes.
Signature (Owner/Agent)�•di
PERMIT PERMIT0k30
.'BUILDING
79
DATE VALUATION LOT TRACT
. >'�2U,t1i�,esti .
JOB SITE
ADDRESS tg Qt/iiv1�� �!.Aa esilO
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
HILL & %AnTY WL. VER,M-
MBIRAM POOLS ND RPAS
49 20.1R"CHO.SAW IMANCLSQ;U:GTO .
4 6880 MOLWfAax CUA J.)17U' L r,94
LAQUINTA ,,A 9,2253
INDIM ANFLIAS CA 92210
0160)345-1376 CMLl 6697
USE OF PERMIT
POOL VIDJOR 811A
P00 l:;.M ALARPjISli3_kT&111?,RS StiAI L SE.ild PT ACE A 1' ,PRF -PLASTER
HOPECTION, Fl�I11S't�tl�.1d`1 l� t�(�4�3i3 i F1C?? iC t i��a ra
P00a.AND/00.3 A anon r, Y's
'0►ZdWXrEU L2wr 01LomtVelCff
•a, '.
8L8DKE SUMMARY
PLAN CHECK 1E.E, 10 S -(*0-439.-318 SIAM'
CONSTRUCTION FEE 1014)00.416-000 $30'7.00
MECHANICAL 1 -- POOH. 101 ^000421 4,100
ZLWT12. ( "FE 9 •= P001. 101-000.42.0-000
PLUME3t1•ir3 Fly ,. POOL , '101-06.0419-000 527.00
'MAR 1 1 2003
®o_QQ••{{�� ••��yy•��..��++ppyy /�1y�p{ � T �L�t CHITY�yO�Fp�L.gA QUIIN�T+A
i��.aD-SOOLAIL. 4+O A7ERla .. .oN R�.R1vr,Y)X',d OERT '�
((�,� �9 �1 w�•
$43 .55
1EN TIZE-PAD HM
SOM
'rCi'1fAI,1i'=0R'.�' 1':I" ES DUE N`OW
$4 3 755
RECEIPT
DATE
BY .---.....,
DATE'FINALED
INSPECT
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 Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
el -
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
II�� r` �,,G,3 --LA QUINTA SUB -CONTRACTOR LIST.
T
JOB ADDRESSSJ- T Z PERMIT NUMBER C2?p 3-0�� OWNER Gr BUILDEI# Rmap_,wl
This form shall be costed on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work'
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each .applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade] Classification .
Contractor -
State Contractor's License
Workers Compensation Insurance
City Business License
Company Name
Classification
(e.g.. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, GalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
S
11
9635S-0
S rUAJ
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bpi of b
V I
31 O
CONCRETE (C 8) .
�' _C) s:i
f� e
~ ���1"t �G�cN J
'a�r� 7
01 01
0l I�c,
FRAMING (C-5) >. '.
—'f~ L"'-
y. yak
STRUCT. STEEL (C-51)
v�Q�ol�
o
; 3t o
S ('� 1 (�I�
aj- onzqq ��
61 n3
06117
MASONRY (C-29)
PLUMBING (C-36)
kO 3 5SO
�6 W
LATH, PLASTER (C-35)
DRYWALL (C-9) .::
HVAC (C-20)`> . t
ELECTRICAL (C-10)
�b3S�5a
01 3/ b�f
S 1�41yl
p-ZSL '002 %
of 03
3l 6
ROOFING (C_'39)-:..
C=39);.SHEET
SHEETMETAL (C-43)
FLOORING (C=15)''
GLAZING (C'-17):.,
.INSULATION (C-2)::..
SEWAGE DISP.
PAINTING
CERAMIC <TILE. (C7-54)':>.:`.
CABINETS'(C'
LANDSCAPING (C'=27):?:;'
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46880 Mountain Cove Dr. Suite 94, Indian Wells, CA 92210
760.345.1376 Fax 760.345.2476
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I�l� Vii '� CITY OF LA QUINTA
BUILDING & SAFETY.DEPT.
APPROVED
FOR CNSTRUCTION
DATE
BY'eft
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