9905-166 (RPL)u a..
+ ' LICENSED CONTRACTOR DECLARATION
,`I ,hereby affirm under penalty of perjury that I am licensed under provisions of
Ci apter 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
:� C-53 C-8 12131'/2(Xl
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:
( ); P,-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)..
„
(, ) '''las owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business '& Professionals
Code).
(,) l.am exempt under Section B&P.C. for this reason
Date Signature of Owner.
ra -
WORKER'S COMPENSATION DECLARATION. .
Ihereby 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:
Cartier ` Policy No.
"S i.T ;f' 4Tdvv'T3 tt4 i, v4fS-f e03?.� '
(This'section need not be completed if'the permit valuation is for $100.00 or less).
O 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 thatifI should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code • I Shall forthwith comply with those' prdvlslon§
Date .��i / /
' %Applicant%f 4.. f. (e
Warning: Fallure.to secure Workers' Compensation coverage is unlawful and
Shall subject ariemployer to criminal penalties and civil fines up to $100,000, in
addition to -the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a'permit subject 'to the conditions and, restrictions set forth or' his,
application.,x
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or:pursuant to
'..any permit issued as a result of this applicaton agrees to, & shall, indemnify
,&,hold harmless the City of La Quinta, its officers, agents and employees.
,2. Any permit issued as a result of this application becomes null and void if
work is not commenced .within 180 days from date of issuance of such
o permit,•or.cessation- of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is,
correct.,1 agree to comply with all City, and State laws relating to the building
construetidn, andhereby authorize representatives of this City to enter upo,,n
Il
the above-mentioned property for inspection purposes. a I
t
v Ignature (Owner/Agent) ,' y -Date r7f
BUILDING PERMIT PERMIT #
DATE / VALUATION LOT TRACT
JOB SITE
ADDRESS ` 44-910 CA. ,$.E .PLACIDO
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MR, & PNITI�5 ROND AU �
G. H". POOL, CGI` IST' ULKIPION
44-910 C;ALLE PJ.,ACW0
684651'EREZ RD.
GA CaUI°id"a'A. CA 92253
LAi'T-iE aRA.L CITY CA 92234
(760)328-2681 C 131iff Fig
USE OF PERMIT
:POOL.A.-NLNOIR SPA.
POOL ,fir• S%A. OML , ALARMS AS WOR :BAieCti'ER i s RECr+L IRED ro-11
PRE-PLAY1'l~12 LNtif?liC i�U:N
P0-01 :LAID/OR.9PA 121501t1.oi)1,S
PERWIT FE1t. SIUMMAW
P—AN CHEX':`K FEE tlJ.i>Oi)0:;43y-3111 $93.617
_$M4.00_$M4.00y
r{{y+1�1yy`1'? i(1ff'�'6'ryft�?y'pagg:))
�.
pq!!>i-fflN(3(/a�-%glt}3••{(�}p�(f);
-41i:r�o.r 4Y.`li+f'ff.A,T'•-•'.t�t«M!.L„ Atl.�"tJ�/FJ"'+b 1^!,}LSU 17A.00
fk 137CTk1CM.FEE — POOL L 10J-000-•4204)00
PLf:,tMANG FIX -- POOL $27.00
f
SUB `tW.AL Ctj! ST'Rtr t_�i:t N AND P1A! C,:HERCK
5313,60
Crr
le�nSiS ;L'R.�-1?,Adl� 1"t:�S
PAIS ;
$0.04
40,VA), a�r:> r �.� I>♦ C E�NOW
$333.60
SAY 1999.
n,
-
'ATY OF L UWT
RECEIPT
DATE q
By : ` `'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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
Co!, pressor
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
Set Backs
POOLS - SPAS
steel
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
`
May -1;e-99 li;;,-,'UA SUNRI-'->A
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NON i A
BUILDING& SAFE Y,,.IEPARTMENT,
C0NDFR9W7t4(
ACCEPTED FO G(WEL't 1"ll-ION11
SUBJECT TO INSIALLM"I'',N AS PER
PLACID
AND ALL APPLICABLE CUD
By
LOT
PLAN
/Uu .$4bl U -Ju/ r . u..:,
5
20'
ISA
45
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