0108-206 (RPL)H
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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. C14ss°-y Exp. Date
Date`'t' r I % I Signature of Contractof �f f
,-.,--'01NNER-BUILDER DEILA,
f""Hereby affirm under penalty of perjury that Ilam exempt from the Contractor's
License Law for the following reason: W
( ) 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&RC. 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.
1;°'Zdi. IONT 1Cb4 1 1'04 3012003.5
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any.,manner so as to become subject to the
workers' compensation laws of California, a d agree that if I should become
subject to the workers' compensation provi$ions of Section 3700 of the Labor
Code,_ I,shall fofthwith comply
Date: + d Applicar
Warni-W.Railure"to"secure Workers'f('Compensation coverage is unlawful and
Sh9l 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 & eachperson at
whose request and for whose benefit work is performed under or piirsua
any permit issued as a result of this applicaton agrees to, & shall, inderr
& hold harmless the City of La Quinta, its officers, agents and emploIng 2. Any permit issued as a result of this application becomes null and v
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancell
I certify that I have read this application and state that the above informati
correct. I agree to comply with all City, and State laws relating to the bui
construction, and hereby authorize representatives of this City to enter
the above-mentioned prop e y for inspection purposes. ±r
� /f
Si nature (Owner/A ent) + ��` `�. Dater 3 C
BUILDING PERMIT PERMIT"
DATE / / / VALUATION • LOT �,jIW206 TRACT
6 / 7 i
JOB SITE "�.:.
APN
ADDRESS
2N
- -
OWNER -`"F
CONTRACTOR/DESIGNER/EN (NEER
MA1XTICYR M i Jcr0C1AT&15, LLC
Ries B."f MgSWC, RTH POOL Ce.AI.{tTRUC IO
78-505 AMME 52
74552UMIGNPLA030.1
.LA. QUM,& CA 92233
PALM MERr CA. 'g222 a
(760)563--4993 CBU. 3115
USE OF PERMIT
P001. M)NOR $TIPA
PC.:C14JS)'A> ALA"5f13AR:1 IMS SHAT 11, BE IN PIAC E AT .f i�&:.-Pl ASTEOR
1k SM,- l'1CAM POOL, VQ01PMFn4T I',1,I'C1,0VURV, NOT YICLUDED
K101, ANDIO>c'a. SPA I's
E&"1C9I UVAUD COST OF C --OMUC,1101q
&ImmARy
PJAN C11MCK FUR 101-000-43 9-518 t3 $16310
CC?NMIRUC,"1'ION FRIE 101-000-418-000 $75400
MXCI A1~13if;AL FEE --POOL 101.000.421.000 $$2+4,00
FEE — POOL 1,011-OM420-000 $45.00
PLUba044C7 PER -- P.00L 101-000-419-000 00.419.000 $27,00
C011 i'RUC r1`s0N AND P'1AN O,3R.M
$511.80
�T`,ts�=: ERMffI S SITE NOW
lixo
AUG 21 2001
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATES
BYDA
FIN ED
INSPECT•O
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
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Final
PLUMBING APPROVALS
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
(Qy/
%bl
TI
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
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: