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9906-101 (RPL)LICENSED CONTRACTOR DECLARATION ' U) I hereby affirm under penalty of perjury that I am licensed under provisions of, _ ;r`Chapter 9 (commencing with Section 7000) of Division 3 of the Business and. C14 W Professionals Code, and my License is in full force and effect. O=)M -� License # Lic. Class s Exp. Date r --Cl LO 65b12 C_3 .. 4 10131i2iX oZ 19 ta' a �Z f Signature of Contractor o. ti U OWNER -BUILDER DECL�ARA II& WW I hereby affirm under penalty of perjury that II am exempt from the Contractor's U) License Law for the following reason: r' Z_ ( ) 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). ce) () I am exempt under Section , B&P.C. for this reason In N Date Signature of Owner pN U Q 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: Carver Policy No. STATEFUND 0116-19C11-000616011 (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 sh II forthwith comply with t ose provis d s. ate: / � 1 Applicant y Warning: Failure to secure Workers Com 1 sation coverage is unlawful and shall subject an employer to crim n I 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' spection purposes. / Signature (Owner/Agent) f� ��/�' •; Date I 11/ j / 4 BUILDING PERMIT PERMITq r 994.6'•1(I.l. DATE' frFi%73/yljEdVALUATION S14_30%1.0t), LOT TRACT r JOB SITE r ' ADDRESS �aD g�'k�Pfl.lw.@ APN — — OWNER CONTRACTOR/DESIGNER/ENGINEER wAPd"Th .:'1s..C"5f'1 11' _V Ct1LI C.�i`:T�L �'t'C:,S c� SPAS 4100 WIAC AKl"1-:CUR'B.LVD #200 74-725 7L1;NI DRIVE�,'#A, NI_WP()IZT t31?AO ' CA .42660 PALM O1?5t"IRT CA 92260 (760)340-9000 CBL4 35; USE OF PERMIT MOL .ANL1;0k SPA POOL, SPA. & B130 C1T+tLY • ALAIMWBARWERS &RAL'L BE -IN PLACM AT POOL Mg)lIOR 1111F.A K300.00 LS E13111RUMD COST OF CONSTRUMON' I,AN CHEf;'K.! .qtr 109-000-439-318 $.i.OS,3t7 1`113 -SpJ1V.ICAL, FrM -• 1'0101, n 000-X2.1.-OUft "7r7,G�3 q 0.::03: ',TRXAL 1'E.'C — POOL, t'r9.f1lYf}3YNG F'EF, KKA, 101-000-4,19.000 SzV.00 ° w rz:r.,rapu�aclrkr7r��v LESS PI 1'.1.11.9 FFES .0.00 JUN 211999 TM*M, PFORMIT Fs IFN DUE NOW � �r Z1iY ®F QUINT. RECEIPT DATE i BY / DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR BUILDING APPROVALS Set Backs Forms 8 Footings Slab Grade Steel Roof Deck OX to Wrap Framing Insulation Fireplace P.L. Fireplace T.O. Party Wall Insulation Party Wall Firewall Exterior Lath Drywall - Int. Lath OPERATION DATE INSPECTOR MECHANICAL APPROVALS Underground Ducts Ducts Return Air Combustion Air Exhaust Fans F.A.U. Compressor Vents Grills Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Plumbing Top Out Equipment Location Shower Pans Underground Electric Final Gas Piping PLUMBING APPROVALS Gas Test 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 Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Notice Final COMMENTS: CLo