0110-165 (RPL)LICENSED CONTRACTOR DECLARATION
U) ' ". I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter.9•(commencing with Section 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
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r` X561 L, C',xC (s 10it.10e
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Z � Date. % - ti% Signature of Contractor � f t% �' �
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aaar,.s. v
J U 6 OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
LCO ( ) I am exempt under Section B&P.C. for this reason
,�,
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< • Date Signature of Owner
O 0)IL Q WORKER'S COMPENSATION DECLARATION
It (r I hereby affirm under penalty of perjury one of the following declarations:
Lo FQ- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X LU u- compensation, as provided for by Section 3700 of the Labor Code, for the
0_1 Q performance of the work for which this permit is issued.
Q U J I have and will maintain workers' compensation insurance, as required by
O Q '$ection 3700 of the Labor Code, for the performance of the work for which this
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Il rn F- permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier STATE E CO7VfFURATI Policy No. 0401hr.10
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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 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.-
D.ate: � !'r l• Applicant , 4 72,e
Warning: Failure to secure Workers' Compensatiorrcoverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
_addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
' for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned proper y ffo�inspeecction purposes,
Signature (Owner/Agent) �• Date
BUILDING PERMIT PERMIT._ '
DATE y VALUATION LOT QY TRACT
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pp g� qq77
J CC4�5Y.7Yda�
�, fr I �
JOB SITE r 1 ticisAPN
ADDRESS YQ 1V4' 0 LA fyel".f11:'17.A D cRM
OWNER
CONTRACTOR / DESIGNER / EN (NEER
If. DI D" 1 rr , RT LIF'YVELOI%M'r
CA M)RINIA.POOLS & SP C.t V MAN ('10 •
P.O. Do # 016
fX72S :m:,,.Ns.f)l'ii°J_% ,m: m? #A
LA QUINTA CA-. 922SS
;4 P,LM D SY RT CA. 92260
(760)340-9000 MIA 010,453
USE OF PERMIT
POOL ANWAO
y.
;P00141PAO 131. AIRS€. Z21-$te4995. ALARMSIBARIZIERS Slii'1Id< HF1H
PL&CE A`i° PR&PLAR ER INSP,�f:'€'TOK 301.0'. OF 51-110H BLOCK
"KA1111 n4C OSUIR.Ir'OITY 1 0,
POOT✓.A1$WOR SPA 23,000,001,0
31i"f , 'W.A ! 30.00 LF
11M �`M C-018—. OF CO1\f'1ti'7:,l�i'sC°�"J(0.1"1
xi�� �tq�p y ,��^i g�7•Y&, }��gyyN-51
4'dL�":fA.X.�.tlY .07..x. SV.E�l�d5ROd9. ZI.
PLAN CHECK FSE 101-000,439^318 $531.95
CONS'!'R11i;;YION FEE 101-000-418-000 $,4.3.00
Mt t,'X1AN1'~'AL FE,9 - -K)OL 101, 0t161.4ZI.000 $24,00
BeLZ.+(. TRICAL IT - P001, 10 1 -000,420-000 $45.00
D �I
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OCT_ 55 2001
CITY
EI'• C Q3a:i RiTCEC$N E Ali) F�Z.�Ai C'E11?C�EC�t.
U-103 FRE -PAW FJWZ
$0100
4 iil1hL-P1%i►+.> i�.' KEN DUE NOW
$4960.5
T
RECEIPT
DATE
BY
D/a F AL
INSPECTOR
u
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
Set Backs
Footings d
Bond Beam{'/ ,
steel
Electric Bond
Main Drain
Approval to Cover
( C
Equipment Location
Underground Electric
r PLUMBING APPROVALS
Underground Plbg. Test
PipingGas
Gas Test
Electric Final
`{
VL"aste 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
COMMENTS:
_
/ s
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)