9701-001 (CP)LICENSED CONTRACTOR DECLARATION
I hereby affirm un&pgrialty 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 # ` t ��� Lic. Class,,, Exp. Date li'v ;/qt,
l.i is `a
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:
( ) 1, 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.
1''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 ��� . t� 0D Policy No. (� _ 6, aC o �OV08
(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, Ishall forthwith comply wi,those pr�ons.
�
/Date: �� Applicant r
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 purposes.
VSignature (Owner/Agent) f Date
BUILDING PERMIT PERMIT970I-Mol CONTROL#
4571
t��/#� !f�,il11!
DATE 11,6/9-711,6/9-7VALUATION �ili�gynYtLOT TRACT
,JOB SITE ADDRESS 372 .S1O�.���H AIN HILUS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
I.S�1,1,� N111f
C;i�.,CFE`�RIN(A POOLS ��, ,S _A8
.Sty440INA "I; INLk
7+725 JONI DRIVE„ 4A
1 14�'k1ii+il"t1 t'x't. 97hl
PAW 0E!f-,I'C' C -A 920
-
1Pi1f313�l0���l1� C'131.�
USE OF PERMIT
i`t
E'<.1i1.1'14L:K.4.�(� WltSta��>'Ki:�fVL.Y
KA A. ANrh�. R 0*1VA 00 LS
PL.AN0k)F0K 14.9' 101_{0(} 434-i"I8
t'40s ?'F t1('Pfc3WFf+ 101-001711L:1} ( (1 $°'417,4,A)
h'R:rI ANIC''AL MXE -.TOOL ]0►-t;J�3� 12,1 tTt?Q Awa ill
lt[,(3L'IKfI'ALialil ;-1't )i., �1t-O00 b4:S-41t
f?La:ICvIf91t�13:t:L::i-V()(,)L 101000-419-M) S27.W
01-'1'4)`IA! * "�W`311.EJC.`1' ON AND P.I,Pl1N C'iIF�T V
V447 SS
#.T'SS }'124:TAIi1 PEE
$000
` OiPM. VIV#MI11' MYS DIIE.NOW
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
j Steel
Combustion Air
^iRoof 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
PLUMBING APPROVALSGas
Test
_MTe-cffric 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 7 -
Final 0/ -
COMMENTS:
(�+1'iNoaJ �Do�
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)
s COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH nOI Q6
ENVIRONMENTAL HEALTH SERVICES; � I
SUPPLEMENTAL REPORT TO SAN. FORM .#
DATE i
SUBJECT 7t,( r PERMIT NO.
ADDRESS J •�. Q "\C. f
_�
C✓ rc.�� . INSPECTOR
REMARKS:
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DEH -SAN -118 (Rev 2196) Distribution: WHITE—Office; CANARY—Owner; PINK—Office
f
DEH -SAN -118 (Rev 2196) Distribution: WHITE—Office; CANARY—Owner; PINK—Office
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF. ENVIRONMENTAL HEALTH '
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE
SUBJECT �(� t��� •. �• PERMIT NO.
ADDRESS ( x
INSPECTOR i( ! ,)
REMARKS:i2 ILI
,,;ice;• ( r !r it :` 4
Y
DEH -SAN -118 (Rev 2/96) Distribution: WHITE—Office; CANARY—Owner; PINK—Office