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0401-386 (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 License is in full force and effect. License # Lic. Class Exp. Date 614-611 Date = ry 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). ( ) 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 Signature of Owner WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: J -.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 S!`A.i 8 FU O. Policy No. ! *91 i I (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. Date: Applicant PA 4,1 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 inspection purpose l/ / Signature (Owner/Agent) `��','�%� Date 19 /2�i.! BUILDING PERMIT PERMIT# DATE b �" VALUATION • LOT' TRACT JOB SITE APN ADDRESS 79,201, TOM FAZI0LAIV. 4Gi1"M. OWNER CONTRACTOR/DESIGNER/EN INEER ROBERT rs1103)M ; IMr, a'1' E P001.,S fk SP AS 79-28) :CO51r!' 1 AZAO KIP". 30TY11H, R-0, BOX Y19) 1A QLT] j`GtA. CSA P2253 ,t.t>, ODDITA 01.x, 922.53 CJ60)360.3585 CBLA' 1945 USE OF PERMIT .P001.lLW/0-P. UP POOL19PA. A SHALL Ear N Pi.A-t:.E AT PPUE,-PLASTER INSMrlON; EQUIPWrKHT E Cj. OURE OT INCLiJi° D, POOL ANDIOR SPA E.S,009.00 E.MM A7`Tx i) COSM 01'7 Ct3Ns"MYUMON 1510MM PLAN C-1—JECIn° 01-( 00-439-318 $105,30 C 0144 'RUCT'IO)i FILM 101,000-418-000 $16Z(w MT.;il.AAdlCla, PTE ... POM 101-000.421-000 8X00 ELL. RIC AJ, PPY, — POOL tOr -000-420-000 $45,00 PLlTMIRING RF -- P00T., 101-000-419-000 SXR.©(► U 8 FF -g 04 2004 CITE' OF LA QUINTA FINANCE DEPT. ffUB= r0TPJ, C ORTF'.CRITMON AND P11,MT C HEM, &"3a :1.30 1.1? MR11-laAM MTM $0.00 IMML PERM ' IMS )ATE SOW33&1 V) RECEIPT DATE BY DATE FINALED INSPECTOR 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 BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test F%,,7al Gas Piping PLUMBING APPROVALS Gas Test Electric Final Nfpste 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 Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: PRnP 151.50'....; HP �ooy, L=50.00' 119.17FS Ir�1[Uk-A 14.4.iFS... 119.46FS olz 1• q L=14.40 i' 2 1.00% L=2.0'/ r; 0 7C 118.SOTG 1 119.46F 5 119.19FS �/ -cr �7-7-7— L 118. 118.5TG119.0 P 1x114 114.231NV . �� 2 5 L=47.00' 119.OFS 121.OFG as - 00 119.22F5 Q30�� 11^9.4M, F.F. =119.50 PAD= 119.0 119.46FS ta��\ POOL I) 118 1 ttg.t 119.34fS L.— t'� 2.00% 119.r1.Fs Ncpj 119.OFG 7.00TG 5.501NV 2� 2.00% 1. n J 1 UNI STA AR( N G td -es Res, ckoe s 7i' f TOM kcz;o TVL Qoin4- 3 11LDING & SA APPROVED FOR CONSTRUCTION ME BY