0010-151 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under,penalty of perjury that I am licensed under provisions. of
Chapfer,;9 (com'mencing with Section 7000) of Division 3 of the Business and
Professi=hals Code, and,my License is in full forde"and effect.
Lice _e#Lic. Class Exp. Date
4 0.11.31/21C
D to e t t Signature of Contra o �M` +
OWNER=BUILDER DECLARATION.
I hereby affirm under penalty of, perjury that l 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 projecV(Sec. 7044, Business & Professionals
Code). ' . ,
O 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.
VI 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.
cg'P11F. FUND
(This section need not be completed.if the permit valuation is for $106.00.or less)'
O 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 aVo become subject to the
Workers' compensation laws of California. and agree that I should become
suet to the workers',compensaUon �rovislons of Section 3700.of the Labor
Code , I shad forthwith comply+wit hlfq oseeprovlsion,,
Kate: �'i 11 i Avv
ppflcant
t;d c
Warning: Failure to secure WorkersCompensationicove rage is unlawful and
shall.subject an employer to criminal penalties and civil fries 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 Puilding
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for insp'ecfio�n pulkoses. 1_/
(0)
Signature (Owner/Agent) a' , n� '+ Date'
f BUILDING PERMIT PERMIT"
DATE VALUATION LOT'TRACT
JOB SITE
APN
ADDRESS
47-7& VIA MOW AM
-
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
'isAy3,r"�k�,7+&�f'w*e��+`3��,bI%.'t3�'.!#�c d'• ..U:r.�.
1 F�qW . Z 1T, ,Stl, ST, 4106
1p'���/tr,�fga�t•pT,A��.ti:[t32d)t?�..
952e2 DO.S'Q.l'illi7ii\/S'6 LSD.
TIMM CA, 927€0
LUCLERYM VAUSY CA 92356
Q60)705-6045 C'�EM .7I.335 -
r
USE OF PERMIT
POOL AM101P SPA
MCa3•.& SPE.A ONLY, ,Fe.l.,tl'df vM +•_£i:s'tRPJZR,S ..%LAL L HE 7'fsf PIACE Al,
PRMPL STM PHSHICT.ION. POOL Fr<?k7MtiN'1 WCU)Si'3R 18 NOT
1H(1LUDXJ.) 114 THIS F!ERMIT.
POt, L.Kt4k' OR. SPA. La
pp�, Q{����aayy��..��{/yy�i ��nngg7)uu��prr.. A+1}•�wy ,{p7� ��,{�fiT.C��7i�7 �•/•�y�,
• - �i�BJJ.dA4;0�,&x:.�i!• �e0,Fr Kill L�.•,Y/.LV:a R,R�Y�. ICITlJN
1m4-oxw ,
PERMTr EWE SUMMARY
Pl:JaA'iFI.7d�??
NSTitiUM10141 FES Ot iftl5 �l�-t�?� aaa.an
Tie3ECkA,N''9CAL FF — Pool, 1014Y00-421-000 $24,00
ZLZ.CTR1C'AL F" - .1- POOL 101-000-420-000 $45.00
PLUMMIG FEE •- POOL 101.006-419-000 S27 00
�f .Cz�p '�t 7.q�p 1,, 1' �• r , wY ^T tt, ice•
i3t,�.13W7. {.y+2'T4�. V •0, -ST.''O.IC.J..4,0'afia' a;)Ay.Wi.Cq curtric
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-11VAT T, TIERM FNES DUENOW
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OCTA 17 2000,
;
LA
RECEIPT
DATE
BY
DATE F NALED J PESD�JR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
ME.IPHANICAL 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
Bond Beam
Main Drain
Approval to Cover
Equipment Location
_
Underground Electric
Underground Pibg. Test
Final I
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
Sever Lateral
Sewer Connection
Pool Cover
Encapsulation
_
CZ/���
Gas Piping
Gas Test
Appliances
Final
' A
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)
I