0209-192 (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 anG°X'_ `
Professionals Code, and my License is in full force and effect.
License65611
t# a Lic.aClass
tt Exp. Date 1
6.5,`6128 C53 1.110 C_
Date r Signature of Contractor
OWNER -BUILDER DECLARATION
r 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
Sec Ion 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 5,TA'tg C0%1PFX3ATJ Policy No. 046=610-01
(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 pr visions of Section 3700 of the Labor
Code As al forthwith comply with thos�p�rovisio s,:- �%
Da.-.,, Applicant ✓ !� ��'�*
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
fora permit subject to. the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application -is made & each person at
whose request and for whose benefit work is performed under or pursuant. to:
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such ,
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon _
the above-mentioned property for inspect-ton)purposes. �1
Signature (Owner/Agent)�U� (_ 01 2 ��'k✓Dater
Fn_
I
"IMILDING PERMIT PERMIT#
DATE VALUATION ,,ppqp LOT TRACT
JOB SITE
APN
ADDRESS 79-.710 RANCHO TA QUIN A D.1WIE
y
OWNER
CONTRACTOR / DESIGNER / EN (NEER.
W D&R F RVEMEWWPUENT
4 A .114ORWLkPt 010 SPAS (100 MAN 1
PC, DOX 1716
86-100 .tail: TOR 54
-QDDITA- - - ` ^,r - A - 92253 -
COAC:EMLtA CA, -_92236-_--
A, _ "9Z2 36 `_ "� �" �--,
('i60)398.9 2.2 CBL 06355
(760)398-922-2
F
USE OF PERMIT
POOL "Y)KfR VA
.?001.,SPA, 'T LY, 5'BLOCK K WAII, CITY u'1M4DARZV.
11491TIAR.ittfi: RS 9 HALL8It 04 PI AC:9 AT PRE-i''WIT ER IN9PP.A;TIOW
SI•SMW�ALyL� 7.00 L
d'�J1l�.t►0'V i//f..IR .�'1.["S-w � l�p��.WV ):.fi)
Ev ATED'C OSM.°;Ulf' C ONUIROC 10N
PLAW CHECK 1 101.000,439.318 �a��.•�s►
CO]d5'rPWCT1014 YEZ 101-000-41,1011-000
MECHANlt'..A1.I- • POOL 101-000-421.000 024,00
ELECTRICAL L HSM -• 'PL7OL V$.00
PY1lJIt9L9I'R1G AtIi, a- F401 i, ' 101000- 1tR-0 30 $27,00
SUB-7'OTAIXORMUM C7N AND c�:yy.F.tl
ppGFt
•�fl','4t�.aAN
YY14L MUMT FE, Es DOE Now
i
$422.70
�Fp 2 5 2002
CITY OF LAQUINTA
FINANCEDEPT.
_
RECEIPT
DATE
y
BY v
DATE FINALED
INSPEC -
Lf-
5 r -i
■-,
' INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
BUILDING APPROVALS.
MECHANICAL APPROVALS
,s
Set Backs
Underground Ducts it
Forms & Footings
Ducts [
Slab Grade
Return Air I
Steel
Combustion Air i I
Roof Deck
Exhaust Fans f
0. K. to Wrap
F.A.U.
Framing
Compressor {
Insulation
Vents I
Fireplace P.L.
Grills I
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines I
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel l9-0 -.z——
Set Backs
Electric Bond p_ 2:1—z
_Footings �� v� L- _
Main Drain p — z,—z
Fiond Beam / _ —
Approval to Cover —g Z
Equipment Location
Underground Electric
Final
_
Underground Plbg. Test (P -
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final s
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
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)
COMMENTS:
' 1!i
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