0205-025 (RPL)LICENSED CONTRACTOR DECLARATION
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
.55? 140;'S3 F31lIC a 11B(
Date" Signature of Contractor ' ?'` n.1 ;.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that"] 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).
t
( ) 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.
a( ) I have and will maintain workers' compensation insurance, as required by
Se�tion 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 I.rA:'TE FLT14D Policy No. 1WM-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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. �e }
'Date:Applicant—
Warning:
pplicant 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.
M
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 property for inspection purposes.
r
Signature (Owner/Agent) ).-''� :-,.,*",.rt 7.. % r `r!► Date c-
II
PERMIT #
BUILDING PERMIT
WX". 12S
DATE VALUATION swimm LOT 5 TRACTO
JOB SITE ADDRESS 61-0,90 CF...Al�ii. CJAF"
APN _ r
OWNER
CONTRACTOR / DESIGNER / EN (NEER
W1'+"i OPFWIM, .RS, LLC
CA, PA.MIC PC3L.3L
55-920 11GA SLV.D-
11, 0..I OX.180 4
i.r3 u'tf F'CA CA 92253
PALM EMIR1NGS CA 9.2263
(760)322-7782 C TUT 6219
USE OF PERMIT
F001, /010M
P001APA, Al..c RMSIBAM.ERS Sti,A. —1 HE fN PLAG:Ir PRIOR TO
Vir*i.MD/ORSPA 34000.01) L;i;
.P1 ' bM''1 SIMM, AR Y
PLAX CHUC'1. FEE 101.000.439.318 V t3 '93
C 014STROC'TION FEF, 101-400-418-000 $284.
i IC HA' TICAL FRE -.. POOL 101-000421-000 42410
z%A.$eC TR.I.S:�.c� L JI .-. FOOL � 0i -�)Q0� �•2CHOt1t7 $45.00
;PLf1MBINO FER -= POOL 101.000.419tl000 MA
5:
fi t PERA"!f"E PEEN DUE IfC3W
MAY U 3 2007
CITYOFLAQUINTA
FINANCEDEPT
RECEIPT
DATE
BY
DATE FIN E
INSPECT
S76
8
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
I Vents
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
rnem I I POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underaround Electric
Final
Gas Piping
_ 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 /J
Test
Final
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)
npr 26 02 00:14a The Summit at PGn West (760)777-9769 p.2
APR -25-2002 THU 02:34 PM K5L DEVELOPMENT CORP FAX W). 7130 5648000 P. 02/03
DEVELOPMENT CORPORATION
0
Apt.il 25, 2002
Southern Hills Devclopntcnt, Inn.
Attention: John Read
55461 Sowhcrn Hills
i„ t Quinti, CA 192408
RE: fool Plans, Loi 58, dated February 28, 2002
Dcar John:
Upon review of the above referenced plans, the approval is for digging the pool only.
Whcn Cindy Zamora returns, she will review for final approval.
If you have any questions, please advise.
Very truly o rs,
William J. Dodds
Senior Viec President
cc. Cindy Zamorcz
55920 PGA Boulevard 0 b Quinta, CA 92253 • (760) 564.7166 • Fax (760) 564.7131 .
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