0104-005 (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 arid effect.
License # Lic. Class_ EO. Date
��}
Date Signature of Contractor �r
OWNER -BUILDER DECLARATION'—;W,,,
;�. '
I hereby affirm under penalty of perjury that I ami6xempt from the Corltractorsr
License Law for the following reason: //f
( ) I, as owner. of the property, or my employees with wages as their sole
compensation, will do the work, and the r,/tructure 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:
( ) I have and will maintain aCertificate 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
Sec
}ion 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 $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any personin•any manner so as to become subject to the
workers' compensation laws of California, and agree th t if I should become
subject to the workers' compensatiojn provisions of Se ion 3700 of the Labor
Code, I hall forthwith comply with t%0S_'ZPr�viSXJ$S.
Da et : 4-iao, Applicant
Warning: Failure to secure Workers'JCompensatlon coverage is i0Alawful and
shall subject an employer to criminal';penalties and civil fines up to $1.00;000, in
addition to the cost of compensation, damages as provided for in,Section 3706
of the. Labor Code, interest ano;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 perso a `}.
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.
J;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 buildingl
construction, and hereby authorize represe tatives of this City to enter,ypon
the above-mentioned property for inspectioN purposeYs/.
✓ -Wei
r nature (Owner/Agent)
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BUILDING PERMIT PERM T#
DATE VALUATION LOT 0 1 M -01M, TRACT
14
JOB SITE
APN
ADDRESS
AVE(A JMG,f
..
OWNER
CONTRACTOR / DESIGNER / EN (NEER
5 —X170.)%gq".M).%1lWUDAD,31�Y.fYfi.,'.,r�ri
��• �� �� a ���zs :
1_4 Quwhot CA .02233
1,A QY!! 4—%A CA, 92253
3
(50)564-1566 M4 S3q.
USE OF PERMIT
P001, A AYA SPA
PAPOWSPA,
-
POW SPA,.r1AtyAFcM5MARRIFIRS SHAIJIL, ✓BFB W PLACE AT PR1,.P- PEASTFX
Ksr.)L, RQr9'tPi0NT ENCLOSUPUKHOT DICIAIDEO,
POOL .4NT,r10R SPA LRS
PUM 01=K FE9 587,75
G'aMSTRU TIt3N FEE 101-000-419-000
;ht(RCFM1CAT.1ZE - POOLS 101.000-421-000 524,00
PLIUM1'1 OF -- POOL 101-00-419.000 577.0
£f7Y'.B-i`C1rAL C0149MUMM AND 111:M CRIB
$7318.75
IM 3 PREP i MS
$0100
!nl
D '
1•`AW&I M6 DUF. NOW
$3184%1,
APR 3 2001
CITY OF LA OUINTA
CEIPT FINA SEPT By i%
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
. Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
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)