0104-086 (RPL)LICENSED CONTRACTOR DECLARATION
zi=he eby affirm under penalty of perjury that I am -licensed under provisions.of
H�apter.9 (commencing with Section 7000) of Division.3 of the Business -arid -_
'Professionals Code, and my License -is in full force`and effect. !' ;
License # Lic. Class Exp. Date
°781098 x°5.3 � J w`3
Date' (� �> ? 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:
, ( ) 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.
( )l I have and will maintain workers' compensation insurance, as required by
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.
ISTAT'1s Pr3r1?;2 009140-01
(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 tlose rQ` °visions.
Date: /'i + ' - I! Applicant j` rnC
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages -as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his"
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that. the above information is
correct. l agree to comply with all City, and State laws relating to the building'
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
r� f
Signature (Owner/Agent) i;,rC--" "� Date �'• %��
PERMIT#
r BUILDING PERMIT
:
DATE / VALUATION :'L'OT.•' Qj�-j{'y TRACT
JOB SITE
ADDRESS
APN
4S'-219 XUAR, V���1'iKLAMA
OWNER
CONTRACTOR / DESIGNER / EN (NEER
�4, 3 t� It C)9tif
80 K ORDER TOOL, CtJ
0-210 'ETUND(OOK CHIN
669115 B M7 IR Kr Fl!JrM Ba
:LAQi1afrA. CA 92253
CATITX4MOL.MY CA 92234
(760)328-•1330 PBUft 6433
USE OF PERMIT
Mal. .t ':9lO SPA
NOa?.,fSr?F�o`. ld. "":lFe`I.".�'r$;flRlt'1.M I .tS4L1, [3.T R$1 PI.ACS.A'i PR.&Pi,.,fAS'f"IAR
POOLANIXOR SPA VONA 11.3
Tx+:SY1s"'�<ATIM COY1" 0Y- C"ORMgi'MON,
d�AfolCi.i9'Li�.4. �`,RSr�: f347.E'Y4.C�.i3
PLAN f'w1i'A'8."%?F- 90i-00("39.318 $0169
CON1111"riti.Tr1•"tIONFEE 101-000-47.8-000 $I�i�.t2fl
�i�T.�#A't�kC.�,1� �x�T( -• 1"Li�iy 4i�1"t'l(i0"'��l-OE3t1 �?P1a0
'EL. TCTITIC.A.fr�,ln12SE � POO), 101-t�i�fl�• 20-000 X5.00
PLUMBING
i AND PA C1R0
CON21101 y
$333.601%NY'A
p 1X815 P_�:e;PAM F IB
SID, 00
� : � 1,1leIf, 1 ME N*0W
APR 1 8 200W)"1
CITY OF LA QUINTA
FINANCE DEPT
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 insu!ation
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
Gas Piping
Final
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
Water Piping
Plumbing Top Out
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
-Pool Cover
Encapsulation
_
— -
_
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)
nar ti..=rS 1. .... .• ..
t 4.
SK'3ELD=N FAX N0. 760 328 3290 Apr. 10 2001 03:47PM P1
g� AY {� ^�y le ;�.r�TCON
S. IC BLPool Replastering & Remodeling
68995 B Street, Suite .8
E f
Cathedral City, Ca. 92234
(760) 328-1350 i.
IS j{
April 10, 2001. ,; 1
City of La Quints
78-495 Calle Tampico
La Qui-nta, Ca. 92253-1504
• :�� �, \ic;�ie Gormley.- _ .: '
To Whom It May Concern: .
Henry Rangel has our permission to pick up the plans for the Karma Leon job located at
�S21v Sunbrook Lane in La Quints. If you have any questions, please call us at our
• Sir_ j�relY, -
Robin Basham — Office Mgr.
p� x,30
JRE-INSPECSION ��E PPRpyEO `] S- �. I 0 � �-h � r,
A CHARGED IF THE A Nps ON o o .x
W\�NS ASD }pg CApD SC�ED�DED
I INSPECi10No p�CEPj10NS� 3 �/ S 9 3 ��
3
k�
33�
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a
CITY OF A QUI�U
BUILDING & SAF
DEPT.
ppRoV.ED
t
FOR CONSTRUCTION
Ga DATE