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0209-178 (RPL)LICENSED CONTRACTOR DECLARATION. 1 -hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 70S) of Division 3 of the Business and Professionals Code, and my License is in full force and effect, License # Lic. Class Exp. Date Date ,~ ` �'S" - Signature of Contractor .�'l'JP✓ ' 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: ( ) 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. (Q) 1 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 EXEMPT 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' compensationrprovisions of.•Section 3700 of the Labor Code, I shall forthwith comply with those provisions /Dater- ^n_ Applicant -.1-0,!7' 1�-' 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 th'e Lal)dr'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 buiidi6g construction, and hereby authorize representatives of this City to enter upon the above-mentioned propertyefor inspectfnfpurposes. h /Signature (Owner/Agent) "�� "' U` •' s-'�""p " - Date,9 2 t �' BUILDING PERMIT . PERMIT# 178 DATE / VALUATION LOT �- TRACT JOB SITE ADDRESS TA l��i�e10 APN OWNER CONTRACTOR/DESIGNER/EN (NEER HM HUTT M, D.I:Ayib OW, POOLZ ARMSias LA QUlM-A CA AM PALM D��:MT CA 9..:2111 �/C,t.GOriJ's3SS ("1:LO .4'159 USE OF PERMIT MOL ANDJOR VVA POOL, SPA, BBQ, HANSI -Z21- 9M). MARMlfiARkkUS SHALL BE FX PLA&CII AT PR&PLAST1'#21'NSPECTIO t, EQUIPMENT ENCLOSURE NOT il�.f",L�.V1:9k T3 VALV TION 3WI),1'tfi Le NSMATLZ COQ.' OF CONSINUC' ON MIM0. W. PERAW Fla! 90MMAR-Y PW11 CHECK FEE )01-000-439-318 CG'tNS7'RMI'ICbd PEZ 101-000-418-000 MECHANICAL Y -- .POOP, 101-000-421-000 �a'l4.t>it EI✓i.'x,TRIcw,%L IEE M- POCIL 41101-06V-420-000 PLUMBINO :l U -- POO 1, +.+ 101-000-419-000 V7.00 19Tt3- MATE, f'° k��°.i UC1i0M AND PLAN �;'1=iF=A;�:%° ��� 1.�.:� L00 1?TZE4F'A1DT,= $0100 SEP 2 5 2002 TALrEnW KESDUENOW �.. CITY OF LA QUINTA 4� FINANCE DEPT. 7, RECEIPT DATE BrYJ` DATEF p INSPECT 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 Rarty Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Dowall - 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 _ Underground Plbg. Test 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 Sewer Connection Pool Cover 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) 1� �� . ___ - - r� CITY OF LA QUINTA SUB-CONTSACTR LIST JOB ADDRESS PERMIT NUIMMM OWkER eT �CNF_�c�l� BUILDER 1k�b�� ©�!-S� �Q This forM ShVA hit posted an lh&. Only persons appearing on t is list or their employees are authorized to wort m on this job. Any changes to this list must be approved by the Buckling C3lvlsion,prlor to commencement of work. Fa will re It In page of work andlor the voidance Wof. building permit. For each applicable trade, all Information requested below must be completed aiglicant, °On File° is nat an accealable response. a Ca �(qr 8fata Contree0o►'s License Orltefl alit rt Insn! . C Bud*nw"s tkanse 5 Trade CtaestflCatbn n Company Name Clossilication . (a.a. A. S. C -B) Lkense Number Issxiwl Em. Date Ixxlxxlxx) Carrier Name g. State Fund, CalCompl Pday Plumber (Fermet Vades) Number 11 0oxxal Exp. Data laxlxxhxl EAmHwoRKWo 121 colicau 1: (041 It�S C— -r la�u al►1 G� "1 ISS 1.3°•03 3F N oAr 50 7 N 5�ogt lo )0ZFRAM11IG (Gel p t� iDel*nse ZJxTRUCT. KnEEL 10-111AsoNRV IC-Ze) MI�I LDi..'Z O I ""1 2:� 0 PLUMBING (C -set LATH. PLASM IC.3e1 n C. 3S (J �j �OC%- �5 ' l'0 13� DRYWALL IC -9) HVAC IC -201 ELECTMCAL IC -10) ROOFING IC -381 •, . SHEET METAL (C-431 FLOORING (G111) GLAZIN0 IC -171 INSULATION IC -41 BeWAGE AIBP. (C-42) PAINTINO IC -33) CERAWC TILE (0.84) CABINETS IGe) PRICING IC•131 LAN XWWING (C -27i POOL Gb3 �- M -� qc� C