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0305-087 (RPL)U f— CV U) W r-CYU.� t; W oZr� � O- o H c J 0 LU a - U) Z 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 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. fo,r--this reason Date /�` Signature of Owner,14 "µa- !!l1'F--- 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' compehsation, 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. (This section need not be completed if the permit valuation is for $100.00 or less). V 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 those provisions. Dater°- — /> i— Applicant 1011, —ral 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 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 above-mentioned property for inspection purposes. �' � * S'ig ature (Own er/Agent)';",4'sDate^ l 13MILDING PERMIT : PERM'T>< DATE VALUATION LOT �? TRACT p JOB SITE APN ADDRESS 53.41M ANTI1V�, A VMASCO OWNER CONTRACTOR / DESIGNER / EN (NEER A1CT?,f , Rc7L 8ON OWNER - FilM 13E R 850 X OCA?W BLVD. Y:,C)1+ G BEACH CA 90802 USE OF PERMIT POOI.AN IOR 3PA POWSPIL ALARMI1MARft11v" SFf A1, L"'8» IN PLACE AT P'Ptlf PLASTER -. lNSPECTION, &QUIPMM41 FMCLOSURLNOT MCLUDED POOL ANDIOR. S'PA 106000.00 1,S ,:,►7i11i!AAd M C09.r M'F:✓ONSTdR6J6r.L.3.O 10,0moll P &ff1' 1S"JF k' 9014 /7A'0. Y Ply CHECK FEE 1.01.000.439.318 0&03 CONSTRUCTION FE? 101-000-418-= $117,00 . MECHANICAL FRE -- POOL 101-000.121-0000 $1A,40 1?i,i�C`f RICAL ME «- POOL 943.00 PLUMBING PEE— POOL. '101"000.419-000 $21100 MAY ,.1 2 2003 CITY OF LA QUINTifA - FINANCt DE T STM, -TC' TAI, C;O R .. �T C.i7'Ii C1C M93,-,PAM1'. $0,00 (YPA4, F'lYsi+►W I ++' ':S DTW NOW 94DS RECEIPT DATE BY ,i DATE FINALED INSPECTOR /) INSPECTION RECORD OPERATION j 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 steel POOLS -SPAS Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric O.T Underground Plbg. Test Final Gas Piping 21 PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Fihlal 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:, `: U t� From: Michael Robson Fax: +1(562)4328049, _ To: Lary Shields Mountain 'Fax:' (760)5649591 Page 3 0:6 Tuesday, May 06, 2003 8:51 AM A ichael Robson , M B Ocean Blvd. Apt.1309 t • r Long Beach CA 90802 C tel: (562) 43248049 emaMp®robson@hotmaiLeonm . ' City of !A' Quince Badding and Safety DivisioD ' 78.493 Cain Tampico PD. Boz 1304 'La Quinta CA .92253 May'6, 2Wa Dear Sir/Maadam l Beildine Permit for. Pool and Sys,' ' &420 Av. VeleM La Quin Cowe Further to nmy.app6cation for a buddiag' permit, as described abode, when you come ?� to issae s:eae, wooidyon pease release it to ftr.lAfty Shields, whom I hereby appoint as my -..814m t for thot parpo ` V you have any dour or questions please do mot hegita� to contact me. t Many thanks : t, Yours very truly m� michae! C � I I a. .I iT i J0, B A' D OREBS on Oil at buiWin emit. rvr ON CITY OF LA QUINTA SUB -CONTRACTOR Lt nFlUff WUIWWA OWNHWAaw" Sopt! -SULDFA eW"At: UfA.&FA OvJvpersons appearing on this got or &wk emplbyew & aufttivud towant F on amcift Dmision prow to omrn weeceent of wank.Fabra to comply WM_reUlt A a StopMe of WWk_ WWk* theVoWWli6 line vadursetsu4 *minim am! Irm fwunninewl hw annfirant- wnn F" is nm an ocnantalbiq ragwnss. 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