0302-105 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C-iapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
lLicense # Lic. Class f Exp. Date
8th"15 J J AMC5 ! 3431:rC,r'ij
Kate � .I j � 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.
( ) 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}' Policy No.
(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, fhose;pro visions.
;,Date: Applicant—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation,` damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a- permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application•is made & each person at
whose request and for whose benefit work is performed under or pursuant to'
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
,2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for'inspection purposes.
F
Signature (Owner/Agent) ° Date f' fir' -f '
BUILD NI G PERMIT > PERMIT#
DATE VALUATION LOT TRACT
JOB SITE ALIS O .Z
ADDRESS
APN
OWNlE�Ry
CONTRACTOR / DESIGNER / EYN 1N. EElR�
-U�.✓d'11.Y �T�f.6.�iJa�.t{ii���
JW"'a �.%.id �L`L..I....� Viti.�iY is J.C'y ���Y ��Mi�
45-970LAFWRLA1&
LA QLTMrA CA 92.253
Ca.:CHIMP-AL fw`C'iY CA. 9222M,
(760)27:5-59779 Muf
USE OF PERMIT :w/,_
y
P001, AND/CM 01"A St
P001, SPA', 4 WW EQV'f P,M04T B'NC 0SUR:if,, CITY S9t�1?1;L1ARJJ
r��. tPv�' s�1i 9. . I• BP iAi 7?�� � N' PRE-PLASI'1`ER INSPECT1013.
4 P7T. W&:i, L 0.00 i,F
3%4:35;?l;.1Nf1 OR'SPA 14,004.00 1.41
COST OF �st3M 3`C-� 'L"'�`tOSI
�,���k":t3.►�3
yy�yg�y +y y �y .gamy r"1P"$�'�.Z:`.r�)
.S" k4..tiGSY I� J.4'�� i9i� �:�iR�.i�;0F9.8'H4t5
KIM CH= I;'# -P, 1C1.0-00.435.318 5105130
4;ONSS7'RUIC TIOIN M. iQ$-000-41i!-000 $162910
-'-51 ool,G 101r,000-421-000 $$i.2p 100
Rpm1�.PS:p1�.�y�17�y1sfA�'Rt,,
YFEE
(y ,4.p[t
101-000-4
WadVIC 17,s�6 AL. k'tG.yN:, •. POOL 101 -000-4 MOW y45M
.
1p1,U!!y+dBINO FER -- POOL 101 -0004W_000 S"Moo
M709 AWD
FEB 14 2003 , W8 -1Du�W
�y
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY , /
DATE FINALED
INSPECTOR
INSPECTION RECORD
41 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
BLOCKWALL APPROVALS
Steel
POOLS - $ A$
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
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
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
/
Gas Test
Appliances
Final
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)
COMMENTS:
`
M
(ED
W
C7
IL// A �,,, / CITY OF LA O.UINTA SUB --CONTRACTOR L[ST
OB ADDRESS 4J✓`' " 9?L
O rlL0A PERNT NUMBER _ __ OWNER BUILDER_ DLIA
his for s#tatl� ltd on the ioh w' the 9u16d_pi g ki C_� at A y int a canseiwoua dace. OrAy persons appearing on this list or ttnar employees p yees are authorized to work
n this }ob. Any granges to this list must be approved by the Btj"ng Division phot to conmtancernmA of work. Failure to comply will reauh in a stoppage at work anal/or the voidance
f binding permit. for each a icable trade, all information r ted below rtust be cam ted by icarrt, 'On File` is not an acceptable response.
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CHRISTIAN LOZANO
PAGE 02
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LA QUINTA, CA
DATE: 02-06-03
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02/11/2003 22:32 . 17603228048 CHRISTiAH LOZANO PAGE 05
01