0103-106 (SOTB)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 701)0) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date f m
6868,515 C53
Date s Signature of Contractor) 6n" w
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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&RC. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARAHON
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
"Adrtion 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 Policy No.
,VTATE FUND D46006101 -00
(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 those provisions,
Date:
te:Applicant '1 w 4611-1
ao 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 Safb)--T
for a permit subject to the conditions and restrictions set forth on�t°irs@@
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 tq 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°fbr inspection purposes.
�^ e
Signature (Owner/Agent) 1'_ � i , Date
u — ✓ 6'
BUILDING PERMIT .PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
.78-703 PWA
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Lit f VISTA, DEVELOPNMIT CORP.
CAL, A. P001.8 & SPAS
7789'9'W01X
'l4-725 JQMDTiTVTw AA
PAI M z.•EMi'r< CA 92260
PALM DESWT CA 92260
C160)340-91000 CIAO
5.86
USE OF PERMIT
POOL .fa,'�fiAYR SWR.
COLdR'd'YAK) FOU'NTAII1A.`.S PMR.API^Rf VED Pi..AN,
POOL, ANi7h: R SPA
MMUeATM C061 Or, a wOMMMiTf.°!�ION
FMWI, 6'n, 903MMARY
}'LIW CHECK Fim 1011.000-439-3.18 NO."
(XINS9.` UCTION FEE 101-000-418-000 W.00
9I.,6XTitiCM,'FEE .. POOL 101-00r>420.000 $45.00
P111imankla SEE -m 1200L, 1a31-�?t1 419-fraJ� $ :0tt
k
AR 14 2001
w- LA' A U091
W..9-T(yf.AJ..O01ro T'ti7a-MOI AND PLAX tIMM
$171.95
11FISS PRE -PMD PEF.13
$0.00
b WAL PERMIT K&IS DVE NOW
k ti
7515A.
f
RECEIPT
DATE
BY
DATE FINALED
IN SPECTOR
J r
!
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs ?
Underground Ducts
Forms & Footings I
Ducts
Slab Grade }
Return Air
Steel f
Combustion Air
Roof Deck ]
Exhaust Fans
O.K. to Wrap ]
F.A.U.
Framing
Compressor
Insulation +
Vents
-Fireplace P.L.
Grills
Fireplace T.O. I
Fans & Controls
Party Wail Insulation I
Condensate Lines
Party Wali Firewall f "
Exterior Lath i
- Drywall - Int. Lath I
i
i
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs }
Electric Bond
Footings !
Main Drain
Bond Beam ?
Approval to Cover
i
Equipment Location
f
Underground Electric
1
Underground Pibg. Test
Final 1
Gas Piping
PLUMBING APPROVALS
Gas T
Electric sFinal
Waste Lines } -
Heater Final
Water Piping i
Plumbing Final
Plumbing Top Out 1
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral i
Pool Cover
Sewer Connection i
Encapsulation
Gas Piping 1
Gas Test
Appliances
1
Final
}
Final I
Utility Notice (Gas) I ,
ELECTRICAL APPROVALS
Temp. Power Pole 1
Underground Conduit I
Rough Wiring }
Low Voltage Wiring }
Fixtures
Main Service 3
Sub Panels
Exterior Receptacles I
G.F.I.
Smoke Detectors
Temp. Use of Power
1
}
Final 1
Utility Notice (Perm) }
COMMENTS:
/
% G _ 0