0308-081 (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 and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
777601 C53 HIC, ' 00�9•f3t1�3(
Ate����� Signature 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.'
()K'l 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 STATE FU'NiD Policy No. 229 -Moo
(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'Labo�
ode, I sh 'll forthwith comply with those provisrogs. —'-" `�--------
Date: x'�7 �r'1 :�4pplicant %-/" .% ✓fit, -'7`i'
;moi � �r'"� 1p:., w ..�.-! �, 4,�YT�-�„�•-•-w
Warning: Failure to secure Workers' Compensation coverage .is unlawful and
shall subject.an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of:,the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on , his
application.. I
`1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursua
any permit issued as a result of this applicaton agrees to, & shall, indemtn. & hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and vo
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancella
I certify that I have read this application and state that the above informatio is
correct. I agree to comply with all City, and State laws relating to the build126—
constru6tion, and hereby authorize representatives of this City to enter.upon
the above-mentioned property for inspeciloq purposes;
Signature (Owner/Age nt)"�� -/� r •• Date• J
BUILDING PERMIT PERMIT#
DATE VALUATION LOT .. .TRACT
JOB SITE
APN
ADDRESS '79'-765 OIEZ.XION WAY
s
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
TTUY KAn PPs/A
..
6L-1yVfiJ) RVopi, y1TC
7$-,7650RT,ONWA9'
�t�-1�s0't i�ryU t U �C}X53
LAQUJNIA Cid 92253
RANC— 0A,SLRAt^E Chi 92270
(„iGC+'831-0E360 MIA 3735
USE OF PERMIT
P001-ANDIOR SPA,
POOL, SPA, 15 LJP. 4' LQUIPMENT WALt3 CITY S-I°A DARD
ALA,RJV SMARRIERS-3 SHALL 139 iN PLA.0.{ .AT PRE -PLASTER. INSP.ir. TION.
4 Fr. WALL 15.00 LF
POOL. A14DIOR SPA T6,?is'0.gii LS
ESUMATM COST OF C;ONSTad`SJM101f
27.0 00.00
Py-P.MT FEE .14 UhMIZARY
P1.,AN CHECK FEE .1.01-000-439-318 317h.7;i
CONSTRUC"PILI?) RL rXi d i b•.Q�ii ��5 .o{P
,
MECHANICAL FRE -= POOL I01 -000-42T -000 $24.00
ELECTRICAL FEE -• POOL 101. -000-420-000 $45.00
PLUMBINO FEE POOL 101-660-4,19-000 -4,19.0QC/ $27,00
Q _FITAL x;01515; RITCT COX AND, PL" CIMM
AUG 0 7 2003 •rOx � � � r . 0���
t _
wam
CITY OF LA QUINTA
FNA E
RECEIPT
DATEt',
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover IGPI
Equipment Location
Underground Electric
Underground Plbg. Test
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
Sewer Connection
Encapsulation
Gas" Piping
Gas Test
ARpaiances
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-
I