0107-108 (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 tlis Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
kI +a% 5 C X53 �- -� C�,F.!�31M
Date t7 X/? 6. 'Signatu're of Contractor
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, 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
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 Policy No.0TA71 F. FUND r4940 UNIT 0OW36
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
r subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shalVforthwith comply with those prow�lo� S.
I: Date:_11 3 + Applicant -41 7 k
Warning: Failure to secure Workers' Compensation coverage is unlawful a d
shall subject an employer to criminal penalties and civil fines up to $100,000, i
addition to the cost of compensation, damages as provided for in Section 37
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Saf
for a permit subject to the conditions and restrictions set forth on hi
application.
1. Each person upon whose behalf this application is made & each persor at
whose request and for whose benefit work is performed under or pursuan to
any permit issued as a result of this applicaton agrees to, & shall, indemr ify
& hold harmless the City of La Quinta, its officers, agents and employe .
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.
Signature (Owner/Agent)!,Z. �'-'�-6lP".o 11, s� i� ate 41
BUILDING_ PERMIT PERM T"
DATE VALUATION LOT ilXQ�"i-i,E TRACT
JOB SITE
APN
ADDRESS
g9-02 $".4' LLE OBISPO
OWNER
CONTRACTOR /DESIGNER / EN INEER
R1'1B13 TC) :1+�.�, , S
R AZO POOLS
51-015 CALLS OBIW O
81 -0 18 JAM WAY
1 A Q171'rRA CA 92.23:4
1iJ X0 C.A. 92201'
(760)347-1617 C:1AX, -7,638,, '
"
USE OF PERMIT
POOL AND/010. V
W301, , ONL.Y - PERWIT DOE 'NOT MCLUDE HL.00KE, WAL.L.. ALAS ARX
RROUTi"',ED TO DISTIA :L RD FOR PRE-E7'LA19TEi;Tt I'NSPRC°TIONi
P4~ OL ASI' OR bi''A L.9
EsIrIX& �.I.d� CC)hT OF C0.1�1'.G7'1�'1'C,`UC)"
22,000.00
x �tqs 7®,q-
YSryry;;�gS,Y,�Yp�gg FEE
�C.II]iM:LLti I �f Y3.E dWLSACMAR
..
PLAN CHECK FEE )01-000-439-318 $146,25
CONSTRUCTION r99 101-000-418-000 $235.00
MEC'.!'RIC,AL. FEF -- POOL 101 -000-420-000 945.00
PLUMBING FEF, •- POOL 101-000-419-000 $27.00
JUL 13 2001
CITY OF LA 0 -�_ .r"KL C W711RC3`s2MON AMD PLAN C.k ECK
$443.25
FINANCE DEPT 1'TM-P•AID, JS0.10
TO JAL 11XRWtr FEES DUE 19OW
RECEIPT
DATE
//// 3
BY
DATE FINALED
INSPECTOR
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
Electric Bond
Set Backs
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
Gas Test
y p (
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
�
Final
COMMENTS:
a_�
L
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)
r
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