0302-115 (RPL)LICENSED CONTRACTOR DECLARATION
I[l 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
80 $ 8017 C5.13 11M,
/Date 2h � 0.a 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 p operty, 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.
( ) 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
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier UI4 PT' Policy No. x
(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,
1 shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that -it I should become
subject to they workers' compensation provisions of Section 3700 of the Labor
r,Godeul 'hal orthwith comply with th se provisions.
Date: » O'S Applicant-'
Warning: Failure to secure Workers'lCompensation coverage is unlawful and
shall subject an employer to`,criminal penalties and civil fines up to $100,000, in
addition to the cost of compensatio 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
e whose request and for whose benefit work is performed under or pursuant to
anypermit'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.
1.1.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
fthe.above-mentioned property -for inspection pur oses.
•✓
Signature (Owner/Agerit).Date
BUILDING PERMIT PERMIT#
DATE r,j' Jr VALUA TIONPo% LOT TRACT
JOB SITEAPN
y
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
79-690 UtTo c:=rJ'M
X-,ti,iJ(?ataR�:'�. "�'S .d�'�►:L:k�IIE,�A l";�i't1
CB1.4 31$8
USE OF PERMIT
P00.1:.MWOR. SP A,
P0011SPAA. ,0'���hyTti'.M�7�S,,1l AT -=ZR$ ) fAM, 32, M P1..(k.r A% I
)�'I.SPE X.M. :F...�+li.[i'N.S KWI T ENCLOSURE HOT llVrc,.toU,DED..
P00.11 ANDIOR SPA
21,101 A0 5.81
Aty
CONSTPUCYiON FES
VE4WHtM, FB?. R1-.rrt�-i.i�aUK 00
l L3, CTPJC.&L F'Z — POOL., $45 0
;LU.M8M(J Y919 — POOL 1,01-000-419--000 Mao
SUR -J. A. CONMISMON AND YJX..0) CI.' =h
$ 19 ZUUJ IL
OF LA QUINTA
ANCE DEPT.
RECEIPT DATE d BY DATE FINALED INSPECTOR
^ r' .`
Y
S, 452,40
$0.00
$»4AD
CJ.
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 Pibg. Test
S
Final
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
j, Q
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
/
'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring ,e,
Low Voltage Wiring R{
Fixtures _t
Main Service t
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
)6HT IRON FE1dGIN6
m
x
z
0
R,
:T +12 Y°111 H ANG.
.GE, AND T iLED
3EAM AT +i" V111TH
' ANND TLED FACE
N!G, To MATC14, -�'
COLOR
Cali OF LA
BUILDING & SAF
APPRO
FOR CONSTP
DA 3 () BY,
02/13/03 02:10pm P. 002
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STING c
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� �. C�9c� RI 5 �-r• ,
• CITY OF LA QUINTA SUB -CONTRACTOR LIST
IOB ADDRESS PERMIT NUMBER OWNER BUILDER_..•
'his farm s_Adl be Ankin Jnsnect?nn Gerd at all times In a consorEcuous glace. Only persons appearing on this list or their employees are authorized to work
pasted pa the jp� with the 1 Q
Pn this Job. Any changes to this list must be approved by the Building Division prior to cornmenoement of work. Fa will re It In at see of work and/or the voidance
of. building permit For each seplicable trade all information requested below must be completed by applicant On File' Is not an ttc 0able re ansa.
�r 1
...-..._ state ewdraeme s u■■la■ 11�yrtMrt 0eiosnsH n Inat)rarres I any Business Lberoa d
Company Wme
CYsslioation .
(e. p. A. B. C•8)
Lkanse Number
In ism)
Exp. Date
Ixxtxxlxxl
Carder Noma
(e.g. Stats Fund, CalCoap)
Fday Number
IFonnat Varied
Eap. Date
(xx1xx1xx)
Liaerao Number
CURIL)
Exp. Date
lax/xxhxl
FAItiHWORXIC-12)
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1.30.03
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FRAMNG (G01 •
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4-12-0a,
MAeoNRY IC -2M)
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323-0
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PLUMBING (C -M
LATH, PLASM I0-35)
C 3S
iJ
- aoo:q 015
' ('0
13 q
DRYIMALL(C•81
NVAC IC -201
ELECT19CAL IC -10)
1100F(NG IC•39) •.
SHEET METAL (C•431
FLOORING IC -15)
GLAZING IC -171
INSULATION IC4111
tiEWAGE MP. (C-42)
PAINTING 10331
CERANBC TIE (0.641
CABINETS 1")
FENCiNO IC -1b)
LANDSCAPING IC -271
POOL "3