0110-091 (RPL)LICENSED CONTRACTOR DECLARATION Y
I hereby affirm.under penalty of perjury that9l am licensed under provisions of
Chapter 9 (commencing with Section 7000) of,Division 3 of the Business avid
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
053 DIC, 6r) Wo
Date/fir '� o --'Signature of Contracto;3'�^
r
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)..-. f
'( ) 1, 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.
(r"•) 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 STATI. M -ND Policy No. PW074-01
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code,plsshall-forthwith comply with'those provisions .
Date:' ;t- .. ADDlican$•-fly
^s ter' 1 Z- .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 tathe;cosf 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 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-mentioggcl,prop&i for inspection purposes. —
Signature (Owner/Agent)4%r.--�- /^!•� r�"'g-" t Dare. -%' _>
PERMIT #
BUILDING PERMITo.
��,
DATE t« TTRACT
!
`1 :,ts
•..tea -,
JOB SITE
ADDRESS t
OWNER
CONTRACTOR /DESIGNER / EN (NEER
MX A bad. C:YdAX:1WOOD
0 -KI 1' 130 I)OOL M1TW"G, DIC
79-405 CN_,LRPRQr1PKR0
60 EUCTENTE RDI
LA Q -0w rX
PALM 011)RUT-GS11 C.A. 922.6A
(76Crj32'V?592 C ",% 81
USE OF PERMIT
,a`'VO.4aA,A3.L IOR 9PA. ...
'
PCK)f.JS.F'A ,fl;l.,,lri, .WHAPU IERS SHAL), WE IN PL&CE AT PRiT is'1;.A:'YEP.
I� PYL(°' ION, POOL EQUIPWEN i WC'iISURE NOT MCL,[Ij KID
P00T, AXWOR SPA 11,000,W LS
N;I+L,Ki.rYBfT.Fi�XlnBL iYI A)�.10.6��9
1
PLAN WOE FEF� 101 AIM -M-31 K
0 B-000
S,AECH.Mlts ll:P` F9,9 - POOL- 1.01.000-421 ^ C TCi 124.00
ZI.LrC` WIr A1, f F -w POOL 101-000-420-000 $45.00
`
3?IaU4SMIG ?PAT, ,.. Ft. -50L I014o0t3419-0-00
• o
•
f
OCT 09 2001
•
orr OFC QUINT►
UB XYrPJX0!W.M0ai'10_
$303,90
LEM9 PRE -FAM MRS
$0,00
I
,
RECEIPT
DATED /
BY
DATE FINALED
INSPECTOR
A�1.y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I !
Underground Ducts
Forms & Footings I I
Ducts
Slab Grade j;
Return Air
Steel I;
Combustion Air
Roof Deck 1 S
Exhaust Fans
O.K. to Wrap 11
F.A.U.
Framing ] (
Compressor
Insulation { {
Vents
Fireplace P.L. I s
Grills
Fireplace T.O. I I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I S
Exterior Lath I I
Drywall - Int. Lath ] f
-
I(
l l _
] I
Final
Final 13
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs i !
Electric Bond
Footings 1 F
Main Drain
Bond Beam I I
I I
Approval to Cover
Equipment Location
Underground Electric
d
' L1
I l
Underground Plbg. Test
Final I i
Gas Piping
PLUMBING APPROVALS
I,
Gas Test
Electric Final
Waste Lines 1 I
Heater Final
Water Piping I I
Plumbing Final
Plumbing Top Out 11
Equipment Enclosure
Shower Pans i [
O.K. for Finish Plaster
Sewer Lateral I {
Pool Cover
Sewer Connection ] i
Gas Piping l l
Encapsulation
,a
Gas Test 1 !
Appliances f !
I 1
Final
II
COMMENTS:
11
�I
Final I I
Utility Notice (Gas) t
ELECTRICAL APPROVALS
Temp. Power Pole I { --
Underground Conduit
Rough Wiring I!
Low Voltage Wiring[
Fixtures 1 {
Main Service I t
Sub Panels ; {
Exterior Receptacles .
G.F.I.
Smoke Detectors 1 I
Temp. Use of Power
]{
I I
Final 3 3
Utility Notice (Perm)
vv -":2-5 C 2j�- } jP
`/9- v IAA CO
GATTUSO POOL CORPORATION
667 EUGENE RD..
PALM SPRINGS; CA 92264
OFC (760) 327-7592 FAX (760) 718-4920
LICENSE # 672850 ,
CITY OF LA QUINTA
BUILDING &SAFETY DEPT.
"�Q�
FOR CONSTRUCTION
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