0307-320 (RPL)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. Dom
.448768 0153 B HIC 13l311�C
Bate 7 * 2 f�' i.71 Signature of Contractor ���� �F/�•�
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:
Cartier 97'ATE RIND Policy No. I 996-O:;i
(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 with tho''�,,s�e vision so
Date: 7 . 2. I • L Applicant 2' �"
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 LaborCode, 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.
1 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 for inspection purposes.
Signature (Owner/Agent) A�✓ �- 7 1 Date `�' -2 k' G'
BUILDING PERMITPERMIT#
DATE VALUATION LOT. CW)7- �' TRACT
07/2A/2ai
JOB SITE t�
ADDRESS 76-'r 1:3 ifak�'Ki DESS PLACE
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ROBM. WAITT
S'MIT .POOL.s
78-613 PEERLEaS PLACE
78-409 DARRBY ROA? FAE''RMUDAl`iUNES
a A QUI TA. CA 92253
M10 ("�A, 92202
(76V)200-1110 (BL_9 1151
USE OF PERMIT
POOL. ANDiOR. VA
en'PCONT YA.,tt1) WA.'1 FR 1a'0UNTlUN(l ZSw THAN 18' D&I"TH).
POOLAND/OR SPA. :%900.00 LS
ES17MATM COST OF C;0K11WJC=01q
S,Q1W.(14D
MMM i7 ER NiJMMARY
PLAN CHECK FEE 103.000••439.318 $46.00
COPI;tiTRUCTIOM YEE 101-000-418-000 �3i .00
ELWC"1 PJCAL FMC, 1011-040.420.000
P1.if 81NO FEE 10.1-.000-a 19-000
-<'Ah
C3 1'S"1*R(3CiION' AND PLAIT CCK
n LESS PRE -PAID FM
$0,00
JUL 2 5 20031. ' YETME'ZA`rES ULT NOW
CITU OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE
/
BY �,.•
DAIE`IN9LED''`�
INSPE
/
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTORS.
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts t
Forms & Footings
Ducts t
Slab Grade
Return Air t
Steel
Combustion Air I
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U. I
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills }
Fireplace T.O.
Fans & Controls I
Party Wall Insulation
Condensate Lines t
Party Wall Firewall
r
Exterior Lath
i
Drywall - Int. Lath
1
J
Final }
Final
POOLS - SPAS
r BLOCKWALL APPROVALS
Steel }
Set Backs
Electric Bond }
FIFfings
Main Drain }
Bond Beam
Approval to Cover
Equipment Location }
-
Underground Electric t
Underground Plbg. Test }
Final
Gas Piping }
PLUMBING APPROVALS
Gas Test i
Electric Final
Waste Lines
Heater Final I
Water Piping
Plumbing Final
Plumbing Too Out
Equipment Enclosure }
Shower Bans
O.K. for Finish Plaster t
Sewer Lateral ,
Pool Cover t
Sewer Connection
Encapsulation {
Gas Piping
I
Gas Test
t
Appliances
- I
Final }
COMMENTS:
f
.
;
Final - - -
Utility.Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low VoRage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power'
Final
Utility Notice (Perm)
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UILM0 &'SAFETY DEPT.
APPROVED
FOR CONSTRUCTION p p,r,P•WATCR
1 DATE ?/ �3 BY '
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348768