0212-031 (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. Date
Date f _ ' ^' Signature of Contractor - A ry Ap -O I
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, amexclusively 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.
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 811ATg CotAPE'NSATI Policy No. 046.0006168-02
(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:" > I d Applicant / A' '�r �, ZL
7 .1M' '! K , f!V'+'Ov C (� MOL 'i :.r
Warning: Failure to secure Workers' Compensatiorn coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
�NNIiGailul i.
1. Each person upon whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this, application becomes null and voidD
work is -not commenced within 180 days from date of issuance of su I
permit,"or cessation•of work for 180 days will subject permit to cancellatio
I certify that I have'read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes.
,.-'Signature (Owner/Agent) �•� q!z Date
,j Y,
--"' BUILDING PERMIT PERMIT#'
s<1u.
DATE ""' VALUATION hhqq��pp /q�44��tt�9 dd����11 LOT TRACT
JOB SITEAPN
ADDRESS 79 !W RMCRID A'. 9� A QMM-A URE
-
OWNER
CONTRACTOR/DESIGNER/EN 5NEER
PO BOX 1716
54
s e•eo m•t
C.,.g,, C���..�a
q!vrw v yt 2.
e�.t�x�+��:^,..�s:»�.�xi T.aA. �`2�:f6
� `�iiiii:£Ia B• CBVI t 00355
USE OF PERMIT
5�100L AM/01Y. VA.
POOL,SPA, O.A$ LXWF, VOR niT'1.3RE 8HQ (A' ISW Z21.99-1994
�r��,n9�rl������.i✓�.� �T�6►.fei. +3� T)�T p4��E AT �.��+t.AE�`t`�� �t�I'`�.'rli�ila,
P"00L tLGVA✓IORtSPA i.ia7
Jia& A"1 IND COST OF C014FIR`f,1'+l UM
PIA N CHEM )"' IT 101-000-439,1318 439>,318 $i.i 181
CONSTRUCTICWFKV, 101-000418-000 $189.00
b"21HAVIICA1,11 FEE -- POOL 1011-000-421-000 $24,00
ZLEEVIT IC:A9.,frYE—,.PC'iOL 102-00("20•000 $45.G -'G
PIAIMit:i 40 ita, Pool, 101-000,419-00 0 M.00
:9sTT1:s-':t'0Ter1L CC)Wf1014AWL) K Ak4 M MOR
j .
LES.", 'Fi'1a1? U d'1i 3
sf).6:1(i
TOM, rXT 1•. 'AS. 3VE NOW
$407195
DEC 10 2002
CITY OF LA QUINTA
FINANCE DEPT• a
DATE
BY
e
DATE FINALED
-'
INSPECT
a
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
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond '
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping lT�
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 E. -
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 Power
Final
Utility Notice (Perm)