0110-277 (CP)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
j� 2/218.1 2
Date 1.f1 ' r` �!`1F' Signature of Contractors f�'� ' %F►�`'� '`
r...r ��
U.
OWNER -BUILDER DECLARATION
l.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
rpmpAncatinn will rlii 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
Gode),.*
( ).:i am exempt under Section , B&P.C. for this reason
Date F Signature of Owner
WORKER'S COMPENSATION DECLARATION
Ihereby 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.
,�gf I have and Wilf;.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:
Carver ST.a4e1'1v`1f1AD Policy No. 229W311M)
(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' compensationfrovisiogs-of Section 3700 of the Labor
rCode, I shall fo hwith comply with tho e rosion;'s:- ,
,"*Date: i 1 fe r.{ Applicant'- .r'. r rr
a L�
Warning: Failure to secure Workers' Comp nsat coverage is lawful 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. Eacli.person upon whose behalf thisfapplicafion is made & each person at
whose request and for whose benefit work is performed under o'r 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 resultlof 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 propertylor)inspection purposes.,
�t r
"Signature (Owner/Agent) '� � fir' " Date X- (0/1
�
PERMIT #
BUILDING PERMIT�.��,
DATE pv waUATION �e LOT TRACT
j•l�i �' Y:) f'.�
JOB SITE C rp''my�7 L�
ADDRESS 'J- CJkl.4FYRd�Fi lSt�•iF%
APN
—
h
OWNER
CONTRACTOR / DESIGNER / EN (NEER
'LEIUDA� 'UWr`F; XW10, INC.
r2mya w-1±19'u:!2u, loc.
76.1.20 CAUE W -Tr DO MME 204
78-120 UZ ),WP DO U1ITE 204
9:.Af",sY. WMA CA. 92253
LA t`iUINTA COA 912:5:3
CJ60)56,11-186 Cffi_,4€ SSS
USE OF PERMIT
P001, ANVOR SPA
F+CC: VSPA. N0 .)•i',k:.t3,x'Ert.F?i. ACF 1? T
PPO.P AS`YFA fNisMITTOK POOL %'C4U1RON a` F;1<ff'.•`1.UOURE NOT `
lt�Ctrl)1?�1J.
1Vt AND1011 SPA i2.00tl go '11:�
ISUM IM l OW- W [M11`ArM>C'3CT?'d' N
1214M.00
PLAN C TIEC.X RIE 101 -6,W-439-31 8, 531,75
CONSTRUCTION 'fs`EE 1 AY .00O. s,1ii-ow 1135.00
ELi-CTTbCALY9R,4. 'OL, 101 -(:.00 -10W' -M) � $45.00
P.L17M..t;1fH*1f F°i E - POOL 101-.000.41 19-000 f $211,00
a
NOV 1'
26 2001
!c -f 6 Y 8dd' 3ar:)t �: �'7,-•y�rv.°.t•
41.lk *w o& ed`.'!m Mm 14'.w C'�€?'"
94.7 5
RECEIPT
DATE /c
Ijrjfi �f.
BY
DAT FINA D
INSPECTOR
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATIONDATE
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
steel
Electric Bond
Main Drain
Approval to Cover
Bond Beam
Equipment Location
Final
PLUMBING APPROVALS
41
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
167
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Finale/�
COMMENTS:
y
`
��
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)