0110-053 (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
Date ��{ Signature of Contractor
`F
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).
( ) 1, 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:
Cartier 1',c TE C,())4pSXf,,AT3 Policy No. 04�OO 1b
(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 sliould become
subject to the workers' compensation groyisions of Section 3700 of the Labor
Code, I shall forthwith comply with tho a roviian .
Date: Applicant,. J *:
N . < r '}
Warning: Failure to secure Workers' Compensation coverage; is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, fir
addition to the cost of compensation, damages as provided for in Section 37 11 61
of the Labor Code, interest and attorney's fees. v
IMPORTANT Application is hereby made to the Director of Building and Safe'.
for a permit subject to the conditions and restrictions set; forth 'on h's
application.
1. Each person upon whose behalf this application is made & each person t
whose request and for whose benefit work is performed under or pursuant t9
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 yiull 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 fo nspec iio'nppurppo es.
Signature (Owner/Agent) Jr ' �s�� _ Date f
BUILDING PERMIT PERMIT #
DATE VALUATION LOT. XR;Bii TRACT
� � ��
JOB SITE
APN
ADDRESS'
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ulr N R03Y
ltALWOW(A POOLS & WAS C-(01? MAK C01
22801 MMOSV' , ULTIM 130
74723 JORMIUVE, YUTM #A
CORONA CA 91720
PA;[.%9:MBERT C& 92260
t;`76OY340-9000 (15RU
USE OF PERMIT
POOL AMfORSPA
POOTAP. A.3 &. $49M`i IC M YeEF'PUaR,APP,PWED HBQ..
:ALARKSdSiAFt1'Jt'SlIRS SHALL BF..M PLACE A'f PRY-PLAV ISR, DISP3a,C` IOX, .
c
POOL MM/OR SPA 19,340.00 'sem
1WS1nMX ff) CCW OF CONYMiIMTO
1:'4ER:Mf IM' MUMMY
PLAN Ci' CK 11: E e 101.000-439.318 51.34.55
COM.S'iRUC:TION VES 101-000-419-000 $207.00
"MuCH"1CALYr.&: POOL 101-0004ba-000 MOD
EfAtCTRUCALFEE, —POOT. 101-OW420-000 $45.00
p1t1.Ymmma ice: -- P%go'.L 101-000.419.000 MOO
a a
OCT-, 0 4 2001
CITY OF LA QUINTA
FINANCE DE = C( k.LW MFZK,
T4 111.1a
1:1'383 1 PRE -PAID 1*tM
$0.00
RECEIPT
DAT t
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
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS
��
�K'Q�r��
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
Waste Lines
Heater Final
Water Pi&g
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower PQ;is
O.K. for Finish Plaster
Sewer LatetW
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
Final
Notice
I ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
lough Wiring
Loy✓ Voltage Wiring
Fi!!'ures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utilitv Notice (Perm)
J