0209-009 (RPL)LICENSED CONTRACTOR DECLARATION
.l.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 N Lic. Class Exp. Date
801807 C53 HIC 1 w 1I0°
Date. Signature of Contractor'"r-
�~1✓�
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 I?",ij:.T 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 piovisio�ns of Section 3700 of the Labor
Code,�I-shall forthwith comply with thoso provlsl ns.
Date:°"" Applicant(��q�---------..
1
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 -f damages as provided for in Section 3706
of the Labor Code, interesi 9nd-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 or 'ins ection purposes.
iSignature (Owner 7,,11 Date f
y
BUILDING PERMIT PERMITk
ow
DATE eer VALUATION LOT d�1" TRACT
JOB S(TEg
APN
ADDRESS 44-670 CAUTIZ YLACIDO
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1"FUR. COB -121.
MAMMA.) POOILS AWO SP AP
4 •-670 C:,A. Z.F 11�10
77.700 »141.1,44D 1,11WE M-11HIR
LAQ-13MA CA 92253
PALM DESERT cA 1
t0)200.5888 Cf3I-'� 3158
USE OF PERMIT
P001./;SPA. SHALL BE I'N PLACE AT PRE -PLASTER
INSPECTION. EQUIPMENT EiOWS lRil NOT INCLUDED.
POOL ANUOR 1�31PA Y's
P F9: K'1.1'S!+�/�-At1iY
PLAIN t11W7CK FEV, 101.000.439.3IS
CONSTRUCTION FRE 101 -WO -4 0
DR-MOLeITION t ER 101-000-123-000
M.PZff.F.NIC:AL f+ tIt– POOL 10'1>000-421-.007 $24.00
D' 1ACTR.IC AL FO -- POOL 101.000-4.20-0(w $45.00
'
MDR- I OTAL 1. TT1.<UC'1'.ICSA1' "yyl;��1++ IA'N?'y'!yy1'�•��//i:K�,
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IS "MIT.
0. 00
SEP 0 5 2002 .._.
Cffy01FLAQU1NTq
ANANCEID
4"BY~
RECEIPTDATE
D/ATTEEF ALED
INSPECTOR
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLACKWALL APPROVALS
steel —r y
Set Backs
Electric Bond —ate
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping i[
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 Poweo
Final
Utility Notice (Perm)
FROM :J GRAHAM
FAX. NO. :7603217646
CI Y OF LA Q110NTA
BLAMING & SAFETY. DEPT;
PPROVED
OR CONSTRUCTION i
09/03/02 03:SSpm P. 002
Sep. 03 2002 02:12PM P1
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�1► CITY OF LOUINTA SUB-CNTRACTORLIST4 v7oQQ
slLDER�MPML;s
Joe ADDR1:sAR pM
Only persons appairing on this list or their empmYees are authorized to work
on the job. Any ch to this list must be approved by the sulking Division priorto oommenoars�eM of work, F 11 n 1 to ape of work and/or the vo encs
of bulidi ermit For each 1 ticeble Crede all Information r nested below must be oo bted a Icant. n Fib• Is not an eco able ren e.
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