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0105-234 (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 C53 MC a 1 /: i/If. ate 9 Signature of Contractor ro 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: (,e6ave 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 E�� jA�+W(} J �ppgy9�+�`q 9 Policy No. �eyyyy �2[qq (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 lAse provision . P 5. s >. i Applicant �- 3 7 Warning: Failure to secure Workers' Compensati n 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 Safetyy- 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 id"" whose request and for whose benefit work is performed under or pursuant to any permit issued as a xesult 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:io 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 'off inspe tion purposes Signature (Owner/Agent) ry, Date•- BUILDING PERMIT PERMIT# DATE VALUATION LOT 011.2M 'JOB SITEJAPN ADDRESS OWNER 2.98a WJ AYJY W CmGu; smu; 1.5o CXYRONA CA 9 1120 USE OF PERMIT P4. 01',Ak D/0,','R M,*,! i COAa1'A62RUCAL FOUL & SPA, POOL ANDIDR SE' �1 TRACT CONTRACTOR / DESIGNER / ENGINEER C. ,isI OR!FMPOOLS d+'r. W (TOP MAN 74725 JONI DRAVA ab`' IIE #A PALMDESM CA 92260 (760)340-9000 C rW1 355 2.9,000.00. L3 jk'•JRMff FEE &OHMAR41 PLAN CBWK FEB, 101 -MI -439-319 9 $180.'70 CONSTR�.UC'il'IO FR lu4•dKDS}-Lt10t-f�C{1 Ei .00 WI CHAMCAt FEE 1'Gtob 101-000-421-000 $24.00 LfLEC11;f.ICAL, FEE — POOL 101 -ON -420•-000 545.0 1~'t.iMEITNt1 FFE •. POOL 1©1 -OW -4119-000 SAW DAM-7,OIAL COM: . FMMON AND P®1..P�{ • c1f Cir, FRES MAY 1 8 2001 X ' ES DUE NOW CITY DF LA QUI NTA FINAIVCE DEPT RECEIPT I DATE I d I BY -; J I DATE FINALED I INSPECTOR U irfFJOTJ4� 4.70 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 L Compressor . Insulation I Vents Fireplace P.L. ', Grills Fireplace T.O. Fans & Controls Party Wall Insulation i Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond { �� Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Final I PLUMBING APPROVALS Underground Plbg. Test Gas Piping Gas rest _ 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 Appliances Final COMMENTS: 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) 7 7 7—TW5W,ml') COUNTY Or RIVERSIDE. HEALTH, SERVICES AGENCY - DEPARTMENT OF ENVIRONMENTAL HEALTH ENVIRONMENTAL HEALTH SERVICES SUPPLEMENTAL REPORT TO SAN. FORM # DATE SUBJECT* (,j PERMIT Ir NO. ADDRESS S 1-0 Ckl\j\ INSPECTOR TT REMARKS: 17 ti 0, Art QdQl Q. Ir TT DEH -SAN -lie (Rev 2/96) Distribution: WHITE—Office; CANARY—Owner; PINK—Office A COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY DEPARTMENT OF ENVIRONMENTAL HEALTH ENVIRONMENTAL HEALTH SERVI.CESMS- SUPPLEMENTAL REPORT TO SAN. FORM #,- DATE SUBJECT PERMIT NO• ADDRESS ADDRESS 0Owl,��AA. REMARKS: C a INSPECTOR 1 ' r, v t ; A i' DEH -SAN -1 18 (Rev ziss) Distribution: WHITE—Office; CANARY—Owner; PINK—Office- sk�w'.,'�?t xisi�Y"•.�8�54''t'.u�.t:.i �aa18,dN`..esi,e:Ss:•,F�n� sML4-,e�',.'.rub:.f��.,:;o-i.^.ti�5�i'3,!L^C,fe�};r�:3:;r Mak.nM�.7iic'l:i�:F:......E.-'i�:•:�iL�.�;?,i.3-5.C�A �_r.�'':i!4s CN ,�3h-ri'"t:..�-L-..H. , 7 ..r:- ,�r r§4 -l.:iN• rr:aZ}h �-Si•^:`�::i:t