0308-352 (RPL)0' U)
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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'
656128 C53 Ric, C-8 1.073'1!2(
Date Signature of Contractor "/�'✓'
OWNER -BUILDER DECLARATION .Y
I hereby affirm under penalty of perjury that I am exempt from the Corttra`ctor'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 offe(e for
sale (Sec. 7044, Business & Professionals Code)' ti
( ) I, as owner of the property, am exclusively contracting with licehsed,,
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C. fpr this reason
bate �`� """' Signature of Owner �.
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WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) it have and will maintain a certificate of consent to. self -insure for workers' "
compensation, as provided for by Section 3700 of the Labor Code, foe, 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
%;Z, mit is issued. My workers' compensation insurance carrier &policy no. are:
Carrier VATR COMPER I`aATJ Policy No. 046-64054003
(This section'ne 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 provis ons.
Date:A Applicant_
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer.to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth `on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to,'& shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.'`
2. Any permit issued as a result of this application becomes null and void if i
.work is not commenced within 180 days from date. of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forinspection purposes.
P ,
Signature (Owner/Agent) �' s{ -s Date
BUILDING PERMIT PERMIT"
DATE VALUATION LOT' TRACT
JOB SITE
ADDRESS 7$-MA•i�'.1 WA I0JU GA ,
APN
OWNER ��
CONTRACTOR/DESIGNER/EN INEER
t}„4iJIU BOC3O
C-'6it;C iRNIAPOC7LS SPS (TOP MAN CO
78a680.AV_1 MATClJXNC3A
86.1 00 -AMM 54
. .:L=A C"A '�2;�,�i3
M.t'AC�f� M 94236
(760)398.9222 CBLN. 00355
USE OF PERMIT
POOL AND/OIC SPA
POOL & SPA, PERMIT 0045 NOT INCLUDE BLOC:.'4,b`'ALLs ALARMS �
BARRIERS SHALL: BE IN PI ACE PRIOR TO PRF-PIAZT R 1,'�10PPICTiOK
2001 C'B
000L MIDIOR SPA 17,000.00 w
EFIMATED CQ&T OF t..OR&M C?f[ON
PERAW M 9ti14211"RY
PLM C14ECK FRE D.01 a0Q0-439x31 %:.
CONST'RUCT'ION IES 101-S1fit}-sIi3�4i0f2 �1�30.00
MECHANICAL FEE -•POOL 101.000-421.000 9'24M
:.
F,LECT RJCAfr• PM — POOL .101.000»420.000
PL,11MI INO FSE, -- POOL ' . 101-00,N419,-000 .127, 00
3C1B= WTA%, !001T U(M, 0 AND PLAN CREECK
�3.fi0
103 PIUK-PAID. nEZ
. $0,00
NOW
• SSP 2=2003 ".
(IUINTA
14 1- DEPT: '
1
RECEIPT
DATE
BY '
DAT INA ED
INSPECTOR
tap;'
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
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
-p
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)