0108-140 (RPL)'LICENSED CONTRACTOR DECLARATION."'.",
I hereby affirm under penalty-of.perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 70b0) of Division.3 of the:Business.and
l Professionals Code; and my License is in full force and effect. ,
Licensees�#}}ei r�e2ssLic. Class Exp. yD,ate
Date Signature of Contractor�{
"� OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from thiContractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as h it sole
compensation, will do the work, and the structure is not intended oered for
sale (Sec. 7044, Business & Professionals Code):
( ) I, as owner of the property, am exclusively contracting Ith 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 Policy No.
STATE FUND W. 00610-00
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. rF'
Date:` �� Y Applicant-�',,
Wa_r-ning..,Failure„to.secure Workers'-�Compensation cdverage 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 tees.
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 applicator 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 purpose
,Signature (Owner/Agent) _ ,- �^ Date
=. BUILDING PERMIT"- - PERMTq
DATE VALUATION • LOT TRACT
JOB SITE
APN
ADDRESS
.?9Ab7 T.A.ricmLo
v
OWNER {”
CONTRACTOR / DESIGNERP/ EN (NEER
MA41 DE ice. RA
GA 'OT.'MI-1 )0311 & SPAS.
:L-AQWTA CA 92253
plamDE SU? IT . CA 92260
USE OF PERMIT
)'` C)OWWAtAfl AXIBP1R)3aKRS MUST 89 n-4 PLACEAT PR.'lfPY„A,STER
1 A.i.WAQU Ph�! -lo IriAdaovoun lion wel'ume'l3.
POOL AND/OR 8111A 19,0.00, 00 La
C09:r or i<t�_t�'S'.i'��U'4;a�CC�i�'
a3��CD6M3.i F
�yq� � p q p �ZIFFIAUTM
PLS MB.1.140 KIP, VOOL I'M mrsi0-4`i 9-!0t1D
.
yy��127 n00
T.6 A14 4J6Y.Y: CK Y.r•Ji'i 101-000-439-318 V 29, 0
C'K 143 t�RLt�°' KA4 E 14 1-�l00-418.000 %19&00
1
tLfl�+ iANZ ICIA11 FEE w Pt N- �i , 101-000411-00 $4.100
1;UCTIOL°?AL FFY, . ,P00;t, 101-000-420-000 Wioo
PLUMOTWO 11MR, POOL 101-000-419-000
'�'`.1�LfdXrf'°T 9�3'.At,T1�MW�CMEM
$449.70
.7. n= FRE -PAW PM
D °
$0,00
AUG 13 2002 VKRIMI Irns DM Na
$449-70
'
C LA A
FIOF
FINANCE DEPT
RECEIPT
DATA,%'
Y
DATE FINALED
INSPEC
!°�'
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts A) A.
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
k
_
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location T
Underground Electric
Underground Plbg. Test
l']
Final I I
Gas Piping
�JI
PLUMBING APPROVALS
Gas Test
l
Electric Final
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
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)
it