0102-096 (RPL)LICENSED CONTRACTOR DECLARATION
I hera"y 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
0.3 C27 12'4' 377
Dat � �%���0 Signature of Contractor � ►/,""'` u. 14?
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that i am exempt from the Contractors
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.
STATE E FUND =-Da UNIT 0020130
(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 foldhwith comply with those pfovisions. C
\, Date."� 10/6&L Applicant—
T--7--'
pplicant • ,4a% -eft -» .�FL*a o
Warning: Failure to secure Workers' Compensation coverage is unla ul nd
shall subject an employer to criminal penalties and civil fines up to $100;Oe , in
addition to the cost of compensation, damages as provided for in Section 3706CC
of the Labor Code, interest and attorney's fees. r L
IMPORTANT Application is hereby made to the Director of Building and yam*
for a permit subject to the conditions and restrictions set forth @�isQ
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,tindemnify
& hold harmless the City of La Quinta, its officers, agents ar dibmployees.
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 propertytfor inspection purposes,
Signature (Owner/Agent) � " ( J Datee
�y
BUILDING PERMIT PERMIT#
DAT "
/ x�JptJ� VALUATION LOT ��,_ TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
W-WINRA, SIRNA.
NMIT AL FWWrS
6.04 G�,7:�i�.E-NO=
73.5 60 HIGHWAY I I I c EMIL-* 5
TA i,?1.Yl1d'm. CA 9.2253
PllSd 4 DESERT CA 92260
(-060)568-6'/26 6'126 CIS U 5220
USE OF PERMIT
P OOL,NNIXOR VPA
(1) SPA OMY. .AS PEW A11P.f;°t VEJO PILA `!S r.):NLY.
POOL ANWOR SPA x 11000.00 La
P-Murr E'er SUMMOIRY
PIAN CHECK Plul., P1.90
C ONSTMUC.TICiN FEE 101_060 -ms -003 $126,00
M'F:;�:Ht•°aWj C'.` '$11 YKL °>, pool, 101-000-421-000 '$X00
' YUNMw[Gf L ME • Pt� $45.00
PtUMM, F:a,I '�`00b 101-000-419-000 $27.00
B 20 2001 --
MA
t- LA UU
CONSTRUM109 AND FILM CHECK
W0.90
t SMS ME—P.A"T.) kM
$0100
TMAL F X[?Wf :Y'�5'.PS'DU NOW
RECEIPT r
`DATE] j l !
BY' pr ,5{�! „>
DATE FINALED
INSPECTOR
....�� ^�
INSPECTION RECORD
OPERATION'
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
- MECHANICAL APPROVALS
Set Backs {'
Underground. Ducts
Forms & Footings J (
Ducts
Slab Grade ] `
Return Air
Steel !
Combustion Air
Roof Deck J,
Exhaust Fans
O.K. to Wrap ] {
F.A.U.
Framing J ..
Compressor"•
Insulation J I
Vents
Fireplace P.L. i'.
Grills
Fireplace T.O. j J
Fans & Controls
Party Wall Insulation 1 {
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath i
it
!;
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs ! {
Electric Bond
Footings It
Main Drain
Bond Beam 1 I
Approval to Cover
i+
Equipment Location
Underground Electric
1
Underground Plbg. Test
Final 1 {
Gas Piping
PLUMBING APPROVALS
Gas Test
_ _ ZG1��`I
Electric Final
3
Waste Lines
Heater Final
Water Piping J
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans I'
Sewer Lateral i
O.K. for Finish Plaster
Pool Cover
Sewer Connection : ,
Encapsulation
Gas Piping
Gas Test
Appliances
Finalyf?/r'
COMMENTS:
Final
Utility Notice (Gas) I !
ELECTRICAL APPROVALS
Temp. Power Pole I'
Underground Conduit i
Rough Wiring i.
Low Voltage Wiring I
Fixtures
Main Service I i
Sub Panels
Exterior Receptacles j 1
G.F.I.
Smoke Detectors !
Temp. Use of Power
+f
Final i
Utility Notice (Perm)
LI v rQd
WON,�-
Vi sal of _'!.qb°V`AL"L
r
w
1:0 Ey.0-E.lCtfwi
al Col
C-vc.,
G��-.Ell� �,_,
CERTIFICATE OF INSURANCE
TARGET FINANCIAL & INSURANCE SERVICES
9449 BALBOA AVE, SUITE 205
SAN DIEGO, CA 92123
(800) 450-8013
FAX# (800) 434-8053
NATURAL EFFECTS
ISSUE DATE -
07/19/2000
TRIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANY
A CENTURY SURETY
COMPANY
COM
73-960 HWY. 111 STE. 5 C
PALM DESERT, CA 92260 COM
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
0
TR,
TYPE OF INSURANCE
I POLICY NUMBER I
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (AAM/DD,YY)
LIMITS
A
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
LAIMS MADE (—X—I OCCUR.
OWNER'S & CONTRACTOR'S PROT.
CCP196955
JUN 8 00
JUN 8 01
GENERAL AGGREGATE
$ 1,000,000
PRODUCTS-COMP/OPAGG.
$ 1,000,000
PERSONAL & ADV INJURY
$ 1,000,000
EACH OCCURRENCE
$ 1,000,000
FIRE DAMAGE(Any One Fire)
$ 50,000
MED. EXPENSE(Any One Person
$ 5,000
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS'
NON -OWNED AUTOS
i
COMBINED SINGLE LIMIT
$
BODILY INJURY
(Per Person)
$
BODILY INJURY
(Per Accident)
$
PROPERTY DAMAGE
$
GARAGE LIABILITY
ANY AUTO
AUTO ONLY- EA ACCIDENT
$
OTHER THAN AUTO ONLY:
EACH ACCIDENT
$
AGGREGATE
$
ESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
EACH OCCURRENCE
$
AGGREGATE
$
WORKER'S COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
STATUTORY LIMITS
EACH ACCIDENT
DISEASE -POLICY LIMIT
$
DISEASE -EACH EMPLOYEE
$
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
PROOF OF INSURANCE
I CERTIFICATE HOLDER CANCELLATION :
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT
FAILURE TO SUCH NOTICE SHALL IMPOSE NO OBLIGATION OLIAB
PROOF OF INSURANCE ANY KIND PONITHE COMPANY, ITS AGENTS OR REPRESENTATIVES.ILITY OF
FAX: 760-340-9426
FES.15'2001 11:02 SGIF #5053 P.001J001
P.O, SOX 420807, SAN FRANCISCO, CA 941420807
ComPENGATIOM • ''
N isU R A N G E
FUND
: CERTIFICATE OF WORKERS' COMPENSATION. INSURANCE'=.'
FEBRUARY 15e' 2001 r c�pucY'NUwibF1: ; Z"'Q1 UNIT 0020130'
AR
(;lRTIFICAJ t'': l XPIREd; �•S r�: ��
' I BARBARA SERNIp 'MIIZENCE � R w �i�,�: •` � �
7th -044. CALLE' WRIZ:
LA QUINTA'
Thl9 I9 to oartlfy that we haivo issued o valid. Workers', compensation insuranco policy In a form approved by tha'Cnlitomla
Irirurande C` rnrniasloner to tho employer named belpw fqr the policy period indicated.
This policy is not subjeCt to oancoilatlon by the Fund except upon ton days' advance writton notion to the employer, '
t
Wo w�11 &It{0 pies You TEN days' advonce notice should. this policy be canaellod prior to its normal expiration.
•E - '
rded
This- eertiflcate of Insurance is not on insurance policy and does not amend, ext ond or alter tris ccvlarherage doeffcu.me t the
poli0se listed herein. Notwithstanding dmy requiremont,.term, or condition of. any contract or, athsr•doou,meflt with
respoct ta:whiahvthis certlPlctate of insurance may.be':feauad pr may K1ertlaln; tris.in,^.ur�rwge�uffoId}9.0<by the po�lcles!
descitbed•herein,'a9. JA t to ait tnQ terms, exclusions an4; conditions of such pR116169, y ? •;, .". .;.
Jt
' lU11'HOn176D REPnE.6�it
EMPLOYER'S LIAB'IEiiTY'.LIMIT INCLUDING •DIrFENSE COSTS"' '.i:1;000�IQi RENCE.
A RE -INSPECTION FEE- OF $30
WILL Bf CHARGEO•IF THEAPPROUED }
' PLANS AND JOB. CARD ARE NOT ON
JHE SITE FOR K SCHEDULED
,... INSPECTION ,.
iIIONS!
Yi.:ygb „6.
KR IEG JOHN.
.NATURAL EFFECTS rt.t
P 0 BOX 390375''
ANZA r CA 92539A
I. •1, f
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IAS A (SLUE PATr-ERNkD BACKGROUND