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0310-291 (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'Licemse is in full force and effect. License # Lic. Class/1//Exp. Date 805577 A MC Date ��- ( Signature of Contractor 4 V " 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). ( ) ,1 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 MEMPT 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' compensation provis ons of Section 3700 of the Labor Code, I shall forthwith comply with�hos , ro isions. Date: Applicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation;'damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions. set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, -agents. and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for ins�p°ection purposes. Signature (Owner/Agent) Date BUILDING PERMIT PERMIT# X10-291 DATE VAL'TTJSTI,ON - LOT TRACT - JOB SITE ADDRESS -t,$* A r A APN OWNER CONTRACTOR / DESIGNER / ENGINEER AAI7.i, Y1:.0NW LA1T)L>W C'1`c;E EK .COZ<1'`a U'C"VON 5 3 -:696 AVERMA V1" MC0 ' 28-321 110=0.1'}:1121) LA QLTMT, A CK173M)Rf, CITY CA 922.34 (760)275=-9779 01314 3254 USE OF PERMIT POOL JWDIOR SFA POOI, 40 LV. -S' BLOCK WAL4 CITY S'TAN'DARD. ALAMISMARVEM SHALL, RE IN PLACE AY' PRE -PICAS S ER FHOPECl"IOA POOL .t ND/OR SPA 10,0WA L9 S FT. WALL 40.40 LS x6rM.A77M COST OF COMMij'G'.P ON 10,966.00 PEW= Fn WADA4Ry PLAN C HWX FU 101.000-439x31€1 $81.90 . CONSTRUCTION FEE 101-000-418-000 $126.60 MECHANICAL MR-- POOL 101.000.421.000 $24.09 . ELECTRICAL FEE - POOL, ;,01-000-�"a10-0013 345.'00 PLUM:8i1` O FEE - POOL, 101.0106.4.19.000 D p � w Nov 0.3 2003 CITY OF LA QuINTA FINANCE DEPT' WOO -TOTAL CIDIT9T1�C�T(�' 10,1.4 /A.4 D PLAN'.'"IC $303.010 LESS PRE-P,AID WEI"r $0.00 TOTAII, VMWr MS DUN NOW $M.90 RECEIPT DATE�/ � BY�f;�� M.�'' DATEFINALED INSP l(�- _ o INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Stab 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 Wali insulation 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 Electric1� Underground Plbg. Test O� Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping . Plumbing Final P umbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection -Encapsulation 7 Gas Piping Gas -Test Appliances Final 71 , Q 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) . o w CITY OF LA QUINTA SUB -CONTRACTOR LIST OB ADDRESS OAQ' PERIMIT NUMBER OWNER BUILD6R �>tod his form >dta9gon the ioh with the Buddha ibteoeetinn Card of el Tknoz a eaes�okwt h mea olar&: Orr}y persons appearing on this fist or thwr employees are authorized to work n this job. Any changes to this list must be approved by the SuAding Division prior to eorridnerwernestt of work. Failure to comply will result in i stoppage at work andlor the voidance f buildin permit. for. each a ieable trade, all Information Taquested below must be carnpileted applicairt, 'On File' is not an acceptable re ` se. Thane 1 CJasaNle�llon ' S/rh Ceatda s[ieeeW i :waiMset r e crisinrioa ' C11 Bush kew Oowtrwxir ILmn CC ¢a1Don {e.g. A, 0, C-0 Ueatee Umber - INUUM4 Eap, Dab Cm &" rlarrM Iiu Aa/sat , (*.g: dtata Rind. CJdCoi p) ibieY rrUralei IForraat VwiwW Ego. pale laitt+tx/aal tjgrtse IdatlbC[ Esp. Deb ptaYul WIMIaal r�Irrxwol tlC:v. 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AtiFVM IF�711 ilCep_- —53 1 S00622 I 101'W31 FATS COO i HOZ J 3 3 6 ------------------------------------------------------ CITY -------------------------------------------- .CITY OF LA Wl TW ---- BUILDING & SAFETY DEPT. cuRB FACE STREET APPROVED FOR CONSTRUCTION -------------------------------- --- DATE Y 40'x 6 BLOCK WALL W/STUCCO YLONEN RESIDENCE 53-696 AVE VELA560 LA QUINTA, CA DATE: 10-22-03 ,SCALE: DRAWN BY: CHRIS 233/58 APPROVED BY: 30 DRIVEWAY 3'0 16'6 3'0 16'0 POOL METAL GATE 4'6" WOODEN BEAM POST SELF-CLOSING SELF -LATCHING ' 707-695-6917 TO , DOOR GATE DOOR 1.0 CIRC PUMP POOL 300 SF HOU 5E ^ EQUIP CARTRIDGE FILTER /�% / V �/� 250 BTU G _ ,�. ELECTRIC HEATER .' YLONEN RE51PENCE 53-696 AYE VE LA5CO LA QUINTA, CA )ATE: 10-22-03 KALE: 1/8"=1' )PAWN BY: CHRIS 233/58 �PPKOVED BY: 707-695-6917 Ir 40'x 6' BLOCK WALL W/STUCCO /3'0. < < < DRIVEWAY 3'0 16'6, 3'0-< 5,0„lrolo < POOL METAL GATE WOODEN BEAM POST 4'6° SELF-CLOSING SELF -LATCHING TO SATE HOUSE DOOR DOOR 100 G. PROPANE TANK 0 H POOL EauIP 1.0 CIRC PUMP 300 SF CARTRIDGE FILM 11 KW ELECTRIC HEATER