0311-120 (RPL)U)
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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
Date �� r ` Signature of Contractor ,7?,Z f • hly kly
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.lfor this reason.
D Signature of Owner 11 old4t? A," ( tiroUt.
is r
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:
Cartier Policy No.
(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%
,DateApplicant f'ti�;.n, !" cyt��. +✓1Y �'-� k�'
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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.
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.trepresentatives of this City to enter upon
the above-mentioned propertylfor Inspection purposes.
Signature (Owner/Agent) — F 4•G'Date/ 7 /5/c► -;
PERMIT #
BUIL INC; PEPMITti 03n-120
DATE r VALUATION LOT TRACT
JOB SITE77-965 CA�sI<,AF Ci3i�kIU A3.lI_ A
ADDRESS
APN —
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MOiTz* TAW COVE D1WMV OP1a1.IATI ! 114C.
OWER - BUILDFIR
P.O. BOX 3578
PALM DEi117M CA 92261
�) (MIN
,
USE OF PERMIT
POOL AND/OSS SPA,
F VeJtA1tI!'t-i• 1a(Af'AIL.EC.!ll A7.`.l ti$4lMM.ed HlAt)lsdi lY L' {R4 f I.YY.L L' K.5 A"P>.U`Y IwYLY !^L'ef,L
IMPtECTIrON. EQUIPMMI T 90CI'lfi SIMP NOT IN€CL'UD ED
POOL ANDIOR SPA H1000.00 LS,
l~`. {l'F:I�.I) COSTL' 01? CC1I+Ci"'11<tMMON
�3l�3i3[9.fPif
P3f:1e:k1I.'r F09 ;3i3'.t�Mii`PY
P1AN C3IFP, K MR 101-000-439-318 $'ad 11S
C:O'NS'PZtctt;TI.ON FE -9 101-000-416-000 V 111.00
M Cl1ANMAL FELE — POOL 101.000.421-000 S.24,VO
FIL ECT dCAL rEE »- POOL 101-00"?0_0110 $45.00
t IatiAh'AINC. IRS: -- POOL, 101.000.419.000 127.00
SUB -1 MAL COMM? U MM AAD TAT—AM 7IWK
$249.05
TA3.113MMIM S' ;LS DUE NOW
_...
&.209.05
OEC 0 8 2003
A ;QUI;1!hX�
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RECEIPT
DATE,
BY
D E FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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
BLOCMALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
L V1 f It
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
0
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
_�=d
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:
a�t4),IE7 I
�\ I 18 R/
• FILL O BC NC
ToWAa ru LI
COVERED
G P UNE .
.. r
PATIO '• \ _... - . I 1
I 4 CHINK SATO sK�M
20' 3' 2 WATER F 0.:. •.
R4'.72" Q
C z
RETU
ETURN .a %
NEW 5' HIGH 3ROV
` ,.. WATER " '' / `- BLOCK WALL
�J- RETURN
TANNING LEDGE
\LCORNERSEE
OTE:70 DETERMINE
CORNER RADIUS POINT DO NOT
MEASURE FROM CURB
1
cavi E cu�cNu�uu �
A. P.N.: FUNS PUMA
n LENDEL VENTC
ADDRESS: LENCH DES1G
LEGAL: L6r .24 - BLK
779-GS I AlLe (llc uA9Q4
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CITY OF LA.QUINTA SUB -CONTRACTOR LIST
JOB. ADDMSS ,.......t wimsm OWNER —:. Bl IUM
Ibis in= O* Persons eppearlho an We Hst or their employees an authwizea to wort
on this job. Any manges to fts list must be approved -by the bu*ft 0i4on.prior to eormnencament of work, �.F,a,�d .ro f 1» at90 of word and/or the voldanoe
aI bWdkv permit. For eachsopkable treds. all. Mormationfamostal below must bs eom leted bv awkant.j•'6n file is not ar teble.re "` So.
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