0308-306 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
AI
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).
( J 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 r.( t '. r �:Signature of Owner~?.�_ �^i1�• ^
1 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 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 provision's of Section 3700 of the La_ b&
Code, I shall.forthwith comply with thosQ provisions.
Date: fs = Applicant %7 r'n' s ,R !�
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 applicatonagrees 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 enterjupon
the above-mentioned property for �inspefctioh purposes."
Signature (Owner/Agent) _' :�~ Date r:f # r-••- )
�• e
i
-BUILDING PERMIT PERM'
VALUATION >;;i;�, LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
G'6+.EGC: RY I M01PAT
92253
USE OF PERMIT
P001, A1:WXYR ST'A�
n,J
R`L!liA..y JI'AY ihd'i15. L1J'�IrVo�.it.��..b VI. iR�Ai,..•e YO:r ,�.S4 3.baliL, R,JIA. �
�..Pt'1,G•1'l�.�ll'EI� T"s+P���t",'Cft�'f�'. �;L'�c.t,Cttf,�i�;��Y'�' i�FC`:`i..O�E►li:r',.I'd'�'.1' :1�dC`I,La03y'�� �<
POOL.,04P0R VA' 1lc
€4 �`�:1'.fi9.t3KARN
PIAN CHECK FEE 101 -MID -439-31.13 ffiDB�, fi3
,
CONS i. P`.11C•'P1ON 79H 10 1 • (40(t•,41 R-.000 $1�&.0:.�
.E01 d edit' al'.r RE. -- P+vik?L A 01 -000-4 21 ^000
VAECTRIGeV,ME-•POOL 01 -000-420-000
r
SUP -TOTAL C1014STr_91€r.'',.IaON:IL1' DPLAZ,'
1130 FR EITIA1,1,>:E?UDI
T.0.Ut.
NOW
2003
CITY OF LA OUINTA '
FINANCE DEPT.
RECEIPT
DATE
BY
D411FIN L
INSP
I
V'
a
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 - IM. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
A
Underground Electric
4
Underground Plbg. Test
Final
Gas Piping
s PLUMBING APPROVALS
Gas
Electrics Ftinal
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
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:
AUG -21-2003 15:24 LEE 8 ASSOCIATES ONTARIO
P.01/01
August 21, 2003
City of La Quin.ta
78-495 Calle. Tampico
La Quinta, CA" 92253
Re; Pon! Perrnid: 57 7S5 Seininolr
To Whom It May Concern:
Please allow this to serve as my (Greg Martin-I3omeowner and Owner/Builder)
authorisation for Marie Porter to pay for; apply for and obtain any necess.3ry permits for
the construction of.a pool and spa at 57755 Seminole, La Quinta.
.If you have an.! uestiona, pt ase call me on my cell phone at (900)312-8039,
Cordiall
T.
CT :b'
f`.1CiregUcr[crs•memos�ciryo0a.�uinwswr4 purmiwnc.
TOTAL P.01
G� CITY OF LA QUINTA SUB -CONT ACTOR LIST
JOB ADD-t'cSs f���-------- �:y iR 1 I I K, C rP�( --r_ I')'1c�•r �C: „
l��55 Jrh"1t I�iC��e t-�t'��RMIT VU��IBER .. •.: UES C. r -e �1>�-Y_zlY�. 3J lD_ .—
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T. tissurm_ttop ,P ZoJ.irl'h.G.12�.N:. y� �ti! h _:ns�e,r_;.i= 7IrL�L:711 -i,m?s `n-,� cunspicyou; :�la.ce. ,nly o yon ,pUt:oring an r:1s !i: a. it their ::rn:ll:,•/rxl ritrit+to work
.;n the lob. ,any r.narrpa it) this list lnust u� touro•n;d by the Building i)ivision u -iur to enrnme(e:.rnent )I w•.vk. Failure to curnply +veil r�:;ult 1n aupt�arla ut work �tniNor the o'd ca :u
o! building .,mit. For 9i1:h applic.ahlr; trade• ill inforinatimi requested helow rust br+. Complet-1!d ay apalic.int. 'On File" ,s nn1 in 'ta:aptabl? tesponse.
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Comuanv Name
Cleaaitienrinn license Number
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re.•d. itile Fund. CBICDIO01 - IF'armat
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"��f 70-445 CALLE TAMPIC-0 -- LA OUINTA, CALIFORNIA 92253
TELEPHONE (760) 777-3092 FAX (760) 777.7011
0WW>FR;FlU1.D>ER INFORMATION
ntv property 0-+•n
An 1rr1i-1r;nn C,. , <<,;I.1 r, prr" sjt !-a• 1,.rn !.;�rr;:rrrd in ymur name listing yoursclf as the builder of the pmperty
impro-t•cmcnts spccifrcd .
For vour protection you should he awuie char as "Owncr/Builder'' you arc the responsible parry of record vn.sw,h a
permit. Building permits are nest required r;, be signed by property owners unless they are personally performing Their
own work If your work is bctnR performed by someone other than yourself. you may procecr yourself from possiblc
list tihry if that pctsan applies for the proper permir in hit nr her name.
Cr-ntrscmars nre tr.giurcd by law ro be liren."d and bonded by the Srate of California and to have a business liccnsc
from the 17iry or Cotinty. They'arc also rt•guircd by law to put their liccnse number on all permits for which Arty
apF!v,
if ymil ri1r, ries vrwr n« -,irk_ with tl,e exception of ,amus rrades rhar you plan co subcontract. -you should be
parr of the 1rf^0-at;e1n fev ves•r honeFr ani prntrrrinn:
if you employor otherwise enPage any persons ether than your immediate family, and the work (including materials
and other costs) rs 3200.00 or more for the entire project, and such persons art: not licensed as contractors or
,ubcontrartors, then you may be an employer
if vin arc an 71ttpinyer, ynu mi.tst regoier wirh the Sr.ate and Fedrral revernment as an employer and,you are subject
to ,rvrral nhlipatjnni includine Statc and Fcderal inrnme ta-r wirhholding, federal social sc(uriiy taxes, worker's
rnmpetrsation inmrsnce, dls3hiliry inturinee cows and unemployment compensation contributions.
There rnsy hr financial ris4< for yon if ynu An not carry nut these oShRations. and these risks arc espeeially serious with
revrct to •+nti!et + rc! 1j+^.n�arinn insuranr-e.
icor cont^ rrr•itir infr-rri-m-nal-:nor v^ni nhliparinns Indrr Fcdcral Law. contact the Internal Revenue Service (and, if
ynu ,•i<h. the I !.S. Sma1! Piirrnrcr ArirninRritinn). For mn!e sperific information about your obliRarions under Starr
Law, contact the Department of Benefit Paymcnr.t and rhe Division of Indusrrial Accidents.
If the structure it intenders for sale, property owners who are not licensed contractors ate allowed to pr!rfnrm their
wnrk prrsonally nr through their own employers, without a licensed contrarcnr or subenntractor, only under limited
rnnriirirsns
A frequenr rrartire nFrtnlirrnterl percnns prnfrssina to he enntricMrs is ro acture an "Owner/ Builder'' building
p.,rKiir, rrrnnrn+t,ly implying that the property owner, is providinrt hit or her own labor and material personally.
Ri.rildin4 prrmitt see not required to be signed by property owners unless they are preforming Their own work
pertnnally.
Ir<fnr-*.4t1nrs y hint Fr -n+ rl vrir!nr• Rm1v r• n1>ralnrd !,y contar.!iev the. Contractors' State License Board In your
community or -at lnzo N. `trert. Sacramrwo. Califnrnia 95814,
Please complete and return the enclosed twncr•buildrr verification form so that we can confirm that you arc aware of
nccsc matrers. The,buitding permit will not be issued until the vrriftcation is returned.
Very truly yours,
1-11Y nr L.A 01 ri:�JT1
r�F.f';' f+p Rt'li.i'Ir'� AND FAFETY
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OWNER'S
P?nrFFTY AnnpFss
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>:. CITY OF LA QUINTA`
BUILDING & SAFETY DEPT,.
APPROVED
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by TNe S e4 -rkt-
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