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0106-307 (RPL)LICENSED CONTRACTOR 'DECLARATION I hereby affirm under penalty of,perjury that I am licensed under provisions of BUILDING" PERMIT Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT Professionals Code, and my License is in full force and effect. f �; , �� . S1 ,,P36t(S QPO License # Lic. Class Exp. Date r,7 ) 1 Or,- d U-) JOB SITELLJ ' V'. 03Iq�y hr� �aw^�M+r�� 'ry p ! ry f/�t ADDRESS tZ�D ,,R�t}��TT..;;CC;; [.y�r��)ptl�f.�1�^rpp yy^�,�p•Y a �� Ralf , `p. ,;i �fk l ,a wy . I i �4t1�W 4YJ-TiZGTt7 SEri.GB.lY:L` Lr4.�'Y.•.1Ly. .ICA,A.9�a.Y,.caY OZ Date' /r'> 3 Signature of Contractor'"' P/ f/ ' %� OWNER rl- / OWNER -BUILDER DECLARATION V W - H d I hereby affirm under penalty of perjury that I am exempt from the Contracto�;s 5N-1611 1300 k�• MU4BiLLS 73-960�,rIRWMAY' I I y..OUTIT,. U) License Law for the following reason: � �� �� �� �� ���� � ���� �����P�• L� ����� Z_ ( ) I, as owner of the property, or my employees with'wages as their sole a compensation, will do the work, and the structure is not intended or offered for %,�� C��7�l��� sale (Sec. 7044, Business & Professionals Code). USE of PERMIT ( ) I, as owner' of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals 9T AADpO R :",SPA Code). Cf () I am exempt under Section B&P.C. for this reason PLFS3, iWA„f�M,,Q.Pt,;'tA.,'1A:1�.RW'13 SHALL HE IN PL•.a�CZ AT P RAE,1TL�i,S'ER O C\1 Date Signature of Owner P'P�SPECbd'i�3X POOL EQUIPMENT�:AI"�.':l,'©OURE NOT P3�G'i.UMD. rn a< WORKER'S COMPENSATION DECLARATION O 2 z I hereby affirm under penalty of perjury one of the following declarations: Lo Cc r � O () 1 have and will maintain a certificate of consent to self -insure for workers' X W L= compensation, as provided for by Section 3700 of the Labor Code, for the O � Q performance of the work for which this permit is issued. m Q I have and will maintain workers' compensation insurance, as required by O U Q . Section 3700 of the Labor Code, for the performance of the work for which this li rn H permit is issued. My workers' compensation insurance carrier & policy no. are: 'IT Z Carrier Policy No. - PERMIT # i Q�t9„ TRACT APN CONTRACTOR/DESIGNER/EN (NEER POOL AAiiF R SPA $11000,01) LS ob O STATE FUND 2W.41IMIT00.2000 ��� o"I' 1:���'�°0kr>C`t�3�&"���fakIT�D�T Q (This section need not be completed if the permit valuation is for $100.00 or less). FIMACT, FEE HUMA” y () I certify that in'the performance of the work for which this permit is issued, PIAN CHEM.MR I shall not employ, any person in any manner so as to become subject to the C014S PZUCTIYtaN M.SOP-6Jt3-d4�?-t�l1�i IaPY3iLQQ workers' compensation laws of California, and agree that if I should become myXHA ICI. VEM, -- FOOL, 101-000,4214M $24,00 'subject to the.workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thoa provlslons. % / a Date: 11 -1. Applicant ! � t ,t _ -p� Ta3r$3PA"CPQ i -^t?tP 6 Q�l ��9? ClbP16�7 �2'1.lP�J --Warne grkerso :-Failure to secure Wo' mpensation coverage is unla V u and shall s bject an employer to criminal penalties and civil fines up to $1'00,00i in addition to the cost of compensation, damages as provided for in Section 3J06 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 aut orize5 representatives of this City to enter upon the above-mentioned property ori Inspection urposes. ... RECEIPT Signature (Owner/Agent) Date SEP 10 2001 CITYOFLAC411i l f2'P3-TCyT'. i f���T�P� .:. .. C f BECK $39100 t AWalL,1C .W ,ihSMS. JI: Y ES DOJE HO - e DAA ti �� BY - DArE 1 ALED O INSP T 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 POOLS -SPAS BLOCKWALL APPROVALS Set Backs Steel Electric Bond _ Footings Main Drain Bond Beam Approval to Cover Equipment Location Final PLUMBING APPROVALS Underground Electric Underground Plbg. Test Gas Piping Gas Test Electric Final fit. Waste Lines Heater Final Wates -Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Sewer Connection Gas Piping Pool Cover Encapsulation _ _//9/�`j� �(� �djQ®Q�✓ Gas Test Appliances Final COMMENTS: i 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)