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0110-022 (RPL)
H N LU � O � M � LU G Z r CID 0' 0 CID LU LU rl- to Z M L0 N ON U °' � Q L Q O L X W L — co O rn H It Z_ ob 5 C) J LICENSED CONTRACTOR DECLARATION I 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 Date Signature of Contractors +OWNER -BUILDER DECLA`Fi7�TtON 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. ,,,(• J 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 0;TA1J s'0MP Policy No. Y4901%0290 (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.sh'�I fprthwith comply with those provisions. Date: /O 1 Applicant + "I k L,.,- % Warning: Failure to.secure W6_rk6fS"C6mpensation coverage is unlawful and shall subject an employer to criminal perialties and civil fines up to $100,000, in addition to the cost of compensation',• damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to . any permit issued as'a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Ouinta, its officers, agents and, employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is • correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned propertyti I r spection purposes. Signature (Owner/Agent)t`e Date I' BUILDING PERMIT PERMIT# DATE VALUATION LOT TRACT Ct bt tD. i 1 ; ,758.91 JOB SITE ADDRESS 79.6`. Y" .�L'i MMMO�V DREV . APN OWNER CONTRACTOR / DESIGNER / EN INEEA 79.598 DAME i.J:C71vr'f?RINIS /5.37). ;£IMM.'$ MAD CA r.11253 CAJIMDRAL C"f T3t' C.A. 92,234 (76())778-2700 G', xji .2951 USE OF PERMIT ERS SiiAU BE R419P11110TION. CSL 011ARd:CI'OR SPA .64000.00 l..31 XR It ES'Y7:�fAI�M. cO 'CSF COMPOr;C UC'19fON Mawr Ffia :s MWARY :(''Id&N i:nn u M, 101.000A.39-318 $234,3$ C0113'1' UCTION FEE 1t�1-CQi� 16-Gni© Z, ;tri NECRAIN"I''AL, Cy' fi--1.R,t ol, 10hT4flu's*�#�a a0t�0 $7*00 tai + "i!'it1S"�4L. i 1p. POOL 1111 $45.00 i LUTIA1(il`.9x'G ROW 40011 101 -000-419,,000 $2`1100 DATE I OCT 0 3 2001 CITY OF LA QUINTA IF3,21 3PR&PAMFE BY I DATE FINALED I INSPECTOR $43'7.35 $0,00 $43'%. 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 BLOCKWALL APPROVALS Steel POOLS - SPAS Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final I 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 Sewer Lateral Pool Cover Sewer Connection Gas Piping Encapsulation �� g•_ �( 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: i r f;?EQU IP _ +6 SpA 3110 314 3110 r'. 100' GA5I.INE 3' SPILLWAY 22,0 1016 0 pro ,o'o 20'0 17'0 EXI5TING DECK 1 MELTON' RESIDENCE 1/811=11 79-6.98 DANDELION PRIVE cir of La UlN- A, GA BUIL NG 8 S ETY DEPT. A RE -INSPECTION FEE OF $30 �� ��� WILL BE CHARGED IF THE APPROVED FOCONs uCTio PANS AND JOB CARD ARE NOT ON THE SITE FOR A SCHEDULED DATE .. U v INSPECTION. NO EXCEPTIONS! I�