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0401-193 (RPL)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Fes- Chapter 9 (commencing with Section 7000) of Division 3 of the Business -and N W Professionals Code, and my License is in full force and effect. O =) M License # Lic. Class Exp. Date 656 128 C 5 13 WO o Z � Date A E> 0 4 Signature of Contractor Xv/1' !. J (-) C:> OWNER -BUILDER DECLARATION HLU rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's U) License Law for the following reason: Z ( ) 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). C•') () I am exempt under Section B&P.C. for this reason LO N Date Signature of Owner ON d Q WORKER'S COMPENSATION DECLARATION p - CC I hereby affirm under penalty of perjury one of the following declarations: Lo H Q () 1 have and will maintain a certificate of, consent to self -insure for workers' X LU L = compensation, as provided for by Section 3700 of the Labor Code, for the O � Q performance of the work for which this permit is issued. m Q (U ()' I have and will maintain workers' compensation insurance, as required by O Q Section 3700 of the Labor Code, for the performance of the work for which this d rn H permit is issued. My workers' compensation insurance carrier & policy no. are: Cartier Policy No. o X7'11F IC,g+?t'1'iI 046 68 a3 -2U44 Q J(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" compensatiip provis ons of Section 10,0 of the Labor Code, 1 sh II forthwith comply with/phos pr visions. fir" Date: �'�� 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 .i 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 t is City to enter upon the above-mentioned property for inspection purposes �� - A? r' Signature (Owner/Agent)©� Date s� f BUILDING PERMIT PERMIT# DATE VALUATION LOT �-� TRACT JOB SITE APN ADDRESS ?'9-'941:1117Xk, COURT _ - OWNER - CONTRACTOR/DESIGNER/ENGINEER j+RANIVI *IWF f 1401IBN0 WC CAI_ .NORkvl! POOLS A W,13.S (7, P Dri M CC 9968 X3: 1' STIs, 102 € 6.100 AVENUE, % 54 SA34 D.Ik G0 CA 92131 COAC14R T A CA: 02236 C76Q)398.9222 C -BLIP 00355 USE OF PERMIT POOL ASM/OR SPA POOL/3PA, R6Q (ANSI Z21•58-1890, FIR.1s'PIT (496A.& L) 1tiY,.t`idMMA11.RIFIRS SHALL BE W PL ACH A1' r.'FtEI'W'IER Itd;9I'E C IOR EQUIPMEMT 1INCLOSURENOT 1DIC;I,t1T E.D P001, AND/OR SRA 1u^,�q30.0(t Ian' 'EmMM'ED POST OF CO—NSTRUCTION ig1.7:11W, ARY P C'k1IC"I:. IME 101-000-439.318 slaa.s CONS'1"Rdrd'1MFM 901-000-418-000 $139.00 MECHANICAL FEE -- POOL 1.01.000_421_000 $24.00 EL'ECTRI,CAt. FRM -- POOL 101 -000 -420 -WO $45.00 rLl•Imnrma 1?a -- POOIf 101.000.419-000 $27.00 4 JAN 2 0 2004 CITY OF LA QUINTA FM ANCE DEPT. °i44ECIC� TALCONI'ERU("' ON AND P�yyyI;�Nn366 CTI :1iI1 Ta $4cpl7/.85�i • .�.hA7a7 .7'61dS".t" aPki.8.1A +5'i€l.+J 1i 4'. OV TOTAL FTG'.0IT.F MIS T)Ln4`E NOW RECEIPT DATE i f •,j f -tel {{ BY /• / J / r•Y IL/ DATE FINALED / INSPEC R 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 Wali Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS steel POOLS - SPAS -a��✓ Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover =a (yam Equipment Location Underground Electric Underground Plbg. Test 17--.9- ley _ Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final _9=1✓ 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 g 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: