0403-339 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of.
H Chapter 9 (commencirig. with LSection 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
t- dU-)
Lu
W ,8 C13 arc'8{) /31/o/
r-- Z r --Date '`wrSignature of Con. tractor/�*�^�(
CD 0- 11� ..
J U 0 r'''� yp OWNER -BUILDER DECLARATION
WWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
c'') () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
O�
EL Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W i = . compensation, as provided for by Section 3700 of the Labor Code, for the
Oro � Q performance of the work for which this permit is issued.
Q have and will maintain workers' compensation insurance, as required by
d(-) Q Section 3700 of the Labor Code, for the performance of the work for which this
a rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
O STATE COMMNSAT) ��S �IGv•?�[f�
J(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 subiect to the
workers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Section •3700 of the Labor
Code,,l,shall orthwith comply with those provisions..4
Date: a. V Applicant
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 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 author jet representatives of this City to enter upon, ,
the above-mentioned property for in! sp ct✓ion purposes.
Signature (Owner/Agent). Date�1 `4"
BUILDING PERMIT PERMIT#
4
DATE VALUATION LOT (),103_— TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CALIFORMAPOOU & SPAS (MI, MAN CO]
81-260 AV.I ;NUE 62
86.100 A NLT. , 54
LA QIH NTA CA 92883
COAC:X-L�'1..LA, CA 92236
(760)398.92.22 CEL4 O0355
USE OF PERMIT
POOL AND/OR SPA
FOOL & SPA. I BQe A -143f 2`11-53-1995, FIREPIT 446 tugAl. 0 LV 34
W.Ai,L .ALA.ltM9ff3ARR.1M SHALL BEN PLACE PRIOR 7:O PREPLAS ER
rKSP CT1014.
POOL- AA7Is OR SPA W
:5 Irr. WALL. 16.00 L£+'
l"1091.`+f�F CO.NS�i�97'OrION
.py;tgh
�; p �,�p�y� L k� q. y3+�:tua�y"T��'�A.'1.ED
11 !.e.K'Q.IYA.I.d'.0."'ER a�9rYJd^/.L14'I1�.R
PLAN CH —M FEE, 101.000-439.318 $12125
CaNSTRUCTIONI FEE 101-OiIO-418-000 $134.00
1MiESoHt4NIC.A.L FRE -- N00L 101-000.421-000 U"e4A
EI,F,CT',RiC AL 1 T;:C .. POOL 101 _000.42+0-000 $45.08
PLZ1bb13NO PES' •-1100L 101.000.419-000 $27,40
STRUC11014 r1. CFMM.
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$0.00
2 4 ' �`�
MAR 2004�L. T
TkL:Px~V T TT_FSDaly NOW
CITY OF L.6+ (1:.QiCa £F.
FIPIANCE DE�'`Y.
RECEIPT
DATE /
BY a
DAT I LEDs
INSP QR,.,(
ZP:
INSPECTION RECORD
OPERATION I DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover _
Equipment Location
Underaround Electric
PLUMBING APPROVALS
Gas Test
Electric Final
e Lines
Heater Final
r Piping
t
Plumbing Final
bing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation O
Gas Piping
Gas Test
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice
COMMENTS: