0006-118 (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
373943 O.3 ; �, 0/31/2(Date 7"" _71 Signature of Contractor s
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.
( ) 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 STATE FV14D Policy No.,2"-00 UNIT 0022036
(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
works' compensation laws of California, and agree that if, I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Cdde, I shall forthwith comply with those previsions:-- Vii;
bate: 2 i - i Applicant. -l- -
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, damage's 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 & 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 building
construction, and hereby authorize representatives of this City to enter upon
the adove-mentioned property -for inspection purposes.
lSignature (Owner/Agent) ' --~-' —'^� �"� Date
76".()J BUILDING PERMIT PERMIT#
DATE VALUATIONssn LOTS
TRACT
swoo
JOB SITE
APN
ADDRESS 55-246 TANQ 00D •D.RM
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CWM'Y' CR.OWEE L CO -13WIM
RAZO POOLS
1335 so, wv AiT wr.: TE. 0200
61.018 JAW7, WAY
SAA! BERNARDINO CA 92108
WD10
` CA
92201
(760)3471-1817.
CBL#
2638
USE OF PERMIT
TOOL IANDJOR SPA
POOL & SPA ONLY- AL.ARM618,Ap PJFRS SHALL BE IN PLACE AT
P:JRE-PL,MTFR INSPECTION: T1.110 PERMIT DOES NOT MCLUOE BLOCK ,
WALLS FOS, EQUIPIVILNIT L'NCL.OSUR&
VALUATION 24,500=00 LS
FS'T IAA= COQ OF CORMUCWCDN
2445 )O.00
P13aGTF= SUMMARY
PLAN CHECK FEE 101-000.439.318 $IC1,80
a w
CONSTRUCTION FEE 101-0004118-000 $152.00
jr'
MSCI -4 OC AL FEE -- POOL 101X000-421-000 $24.00
� f
ELECTRICAL PEE—POOL 101-000-4.207000
= I j � • {
PLUMBINQ FRE •, POOL 101.000.419.000 121.00
- ,
m: 7
?j
SUB-T(YrAL CONI UCT 7013 AND PJ -,AM C`.2"•I'E.CX
9.1.80
LEM PPX -PAID
$0.00
TUrAL .PXKMU 11YEt S DAM KOW
9 T=
RECEIPT
DATE 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
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground -
Unde : and Plbg. Test
Final
Gas Pi)�ing
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Ficial
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:
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY.
DEPARTMENT OF ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE
SUBJECT Ll UG C ` PERMIT NO.
ADDRESS
INSPECTOR
REMARKS: LO "0. 01
L)
e
DEH -SAN -1 18 (Rev 2/96) Distributiom WHITE--!-Office;*.CANARY-Owner; PINK—Office
t ^tea+✓' ,.; z 4 A -�` n � �' . a ;+a"., ...i x ''.1 i.i S .�]'!'',7r %�..*-,�� .,�."' �i"7 \',.i�'S� ,Y; "[v7i "�• �"" jr-�'T•°' "Y' f.'•v..'. „x'•a'",�--.vq: .� yT'..?c--:p.r+�dr.-.,.�,,.,,,:".."mw_
d t c a
L;j COUNTY. OF RIVERSIDE HEALTH SERVICES AGENCY. K
DEPARTMENT OF ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE
SUBJECT ' W �SeV PERMIT' NO.
ADDRESS t p s
INSPECTOR
REMARKS:
F'
• , t,.
r �
1A V4
�r
.j
'oEH-SAN•118 (Rev z/ss) Distribution:, WHITE—Office; CANARY—Owner; PINK—Office
, . ,. ?... kxcs.{ lt,a•.'t xaxr4 <--.. - 5....>ri ,. h.... ih r r>a.7 Y ,>., t , _a a �+ A:
..
V
'oEH-SAN•118 (Rev z/ss) Distribution:, WHITE—Office; CANARY—Owner; PINK—Office
, . ,. ?... kxcs.{ lt,a•.'t xaxr4 <--.. - 5....>ri ,. h.... ih r r>a.7 Y ,>., t , _a a �+ A:
� 11 1 ' ! t -T ..M •+Wiwi z'r r r t.
, if. a r 1 y i
� '. y
..�, `
�'� • y ,Fti
t - u j
• � ..
�TMr�T'x ,y,.� U
..'
COUNTY OF. RIVERSIDE HEALTH SERVICES AGENCY,
DEPARTMENT OF -ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE
SUBJECT PERMIT NO.
ADDRESS
Fr INSPECTOR.,
A
REMARKS:
y
1;
Y•
i
+
p:
-DEH=sAN-tts(Rev 2/96)Distribution: WHITE—Office; CANARY—Owner; PINK—Office
,at
s.'".•11'L.-�i.L.,%.nle�.:.x.a5�...�.d..i'.e.F.sla.:c_a Di ��7`._:}-.��f,b.!•.{5�. ..n N",,.'h 'fin. a.29�-'S:� rf.i;A.,•ew%`t+iaS+,rti.'.w,.=4?:�,J:.r!.�..�0��.::f ,.�i.r'.. ..ir,...1. €v (r _: .'.:zS r�,r?::. _+,..... -,_. >.....L - t t.. .. �.,.
y
i
1.
1,7
COUNTY OF RIVERSIDE -A 1430306
R;_Y - 'OFFICIAL -RECEIPT -
ERS
De rtment �.C�Date 2 t
f
Received from
DOLLARS
100 i
Description
i
C
� !
n
COLINTY'OF RIVERSIDE HEALTH.SERVICES AGENCY
DEPARTMENT OF .ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO'SAN. FORM* r DATE U I
SUBJECT ! C> N (I� P .�, . < �(� U '•.� i..�° .,..� , L PERMIT N0.
ADDRESS
;INSPECTOR
REMARKS:�
11.E (`; n
DEH -SAN -„a (Aev 2/96) Distribution: WHITE—Office; CANARY—Owner; PINK -.—Office
�' r..V�..� i..ywlY.liwY.i�r.�.t�iM•+i�!(. `•Y7pr�r^r �.'. %.. (... i..L..._.. �.- J..._ �. - �d •��...,. - J - ... ..
-4��(I r�� C:i..� •�` !
i r_r, Q� 'f ;1 y^ 1
e ! (�' (f C" r t=' (1 C "�
�;
DEH -SAN -„a (Aev 2/96) Distribution: WHITE—Office; CANARY—Owner; PINK -.—Office
�' r..V�..� i..ywlY.liwY.i�r.�.t�iM•+i�!(. `•Y7pr�r^r �.'. %.. (... i..L..._.. �.- J..._ �. - �d •��...,. - J - ... ..