9803-059 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
-Gitpter 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
1 0.5 C 53 /" *� 450M
Date��lr`"' Signature of Contractor,
OWN ER -113 UILDER'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.
F;;mIy1P'[ ION ON FI 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,
Ilshall 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,S ction 3700 of the Labor
Code, I shall forthwith comply with• o e provisions.
t%Date:�L- rrl*°'� 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
thefabove-mentioned property'for inspection purposes.
gnature (Owner/Agent" )r�^ Dat
✓Si
BUILDING PERMIT
DATE ! 1 VALUATION
JOB
615,000.00
79-1.70 LATICO
LOT
PERMIT #
CONTROL#
980"59 TRACT t
8G28
APN
CONTRACTOR / DESIGNER / ENGINEER
MARK LIEBONV VALLEY POOL & SPA
79170 LATIGO CIR 4741 E: PALIN4 CANYON DR. #116
LA QUINTA. CA 92253 PALM SPRINGS CA 92264
(760)778-3939 CBL# 2565
USE OF PERMIT
POOL & SPA ONLY, ALARMS HARRIERS ARE TO BE O:P T10- AL
PRIOR TO EN-CAP/PRE,-PLASTER ION
POOL ANDIOR SPA
15,0m.00 1`13
CITY
T
SUB -TOT -AL CONSTRUCTION AND PLAN CHECK
•. LESS PRE -PAID f{E
j
17 1998
LA QUINTA
t
$363,30
$0.00
TOTAL PERMIT .F E, &S ii3UE NOW $3613.30
ZI. A, ro
RECEIPT DATE BY DATE FINALED INSPECTOR
1'1r199.�►'Y',r D COST OF tS'
CON
ESCT:rON
PERN11T FEE Si13MAMRY
PLAN CMCia FEE
101-000-439-318
X1.05.30
CONS'P UC'TIONF.EE
10.1-000-418-000
$162.00
MECHANICAL FE9 -- POOL
101-000421-000
524.00
%_t.ECI'RICAL FU8 --'POOL
101-000 120-000
545.00
PI.I, NH31NG FR3 __ POOL
101-000-419.000
$67,00
SUB -TOT -AL CONSTRUCTION AND PLAN CHECK
•. LESS PRE -PAID f{E
j
17 1998
LA QUINTA
t
$363,30
$0.00
TOTAL PERMIT .F E, &S ii3UE NOW $3613.30
ZI. A, ro
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
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
r
BLOCKWALL APPROVALSsteel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric 4/1YI-11 17
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
Pool Cover
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
e
Appliances
Final
COMMENTS:
,4/#,em s Zeusnd1/Fay 1~c: PeoG Go,geA
/rloD�L J7� P7—, Sv5r1,x& c;D 4r Yro,*vbw
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
4 ,
f
Final
Utility Notice (Perm)
GITY OF LA QU,N TA-
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SUBJECT TO WS ��.:�����i� � S E
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AND ALL APPIL.r%...ABLE CODES
BY
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CITY OF w QUINTA
SURAW
fANTRACTrue VALL" POOL 6 SpA MOM"17411 E 111 CANYON 1 1116,
pyypEp
L66 JOB ADppA84 79170 LATIGO
It is the neponsibi'lity Of the Genwal Ca lbactoror the Ownw/euildw to monitor the subcatttrao that
we on this Oat am the aims persons pwforminp the*work. Any changes to thh list must be approved the
City of in Quints Depsrtmwa of 9uildirt0 d Safety pM to walk be1g pin formed by a dlanped sub-
contractor. Figure to comply will mutt In a soWsp of work and/or the voidance of building permit.
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