0107-320 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
0y W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
Q u7
oZ Date 0 Signature of Contractor 9�
co O_ r -
J U C:) OWNER -BUILDER DECLARATION
HUJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
.Y 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).
C'') () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
0)d Q WORKER'S COMPENSATION DECLARATION
j 2 z 1 hereby affirm under penalty of perjury one of the following declarations:
_n Q� '• . („)r have and will maintain a certificate of consent to self -insure for workers'
K I j 1 compensation, as provided for by Section 3700 of the Labor Code, for the
DJ Q performance of the work for which this permit is issued.
QU )• I have and will maintain workers' compensation insurance, as required by
j U Q S` eciion 3700 of the -Labor Code, for the performance of the work for which this
L 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
coo O S"'FiM Ci°OMP;EN9. i 1 MUMS
Q (This section need not be completed if the permit valuation is for $100.00 or less).
J ( ) I certify that in the performance of the work for which this permit is issued,
r` 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
3 subject to the workers' compensation. provisions of Sectio %3700 of the Labor
Code, I h_ all forthwith comply with t I O e provisions,%
mate: = �-� Applicant �
b Warning: Failure to secure Workers' Corn pensatio coverage is unlawful and
+-A 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 •r'.s•
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 bu'Iding
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned properfty,forInspection pwrp ses.
°Sig ature (Owner/Agent) + ? + �' Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 8 �}�(��.���� TRACT
JOB SITE
ADDRESS
T
OWNER
CONTRACTOR / DESIGNER / EN INFER
X0p' 3€'�u,�f.��'}{4,'2,}t;'5��lpl:i<ll l':'OAA�LR� 1�:'YES
t':.ptntgL�c?�"tR1�y3'rM.Pyr 010 =�wyrci'.E`AS ('r YP MAK 001
�y
A' !” *01 101 67.i, 49'L:'m r•Jl,. M. M4 O
,�4 25 or�.tiTI Z�.Ci:A'i. ✓, t3��.l� H.N.
8ANr ;'FAWA_9DW0 €,`:A 92,108
PALM D &SUS' CA 92260
(760)340.9000 tom' h 1455
USE OF PERMIT
POOL AMOR SPA
POWSPA. A;+td:'n.;`:'i :ARRIEPRS Silt YJ, HE IN PL A.6>E AT PR&Pi„As T37M"
NUPP C��clt£li44g t StJi .1 Alt�fi . 8C1, t�i?l�.
POOIIANWOR SPA 00 1§1
Vw15rWAUX COW OF CONS",4:.;�1iiC°.f'IO
��,fTl3t3.ildb
TpI'rR-Mrr FET. SUMMMY
111.&N Q-11F.Clit 1F'3 3 � rt�s�{1�K
�04ryry9
CONWROCTZON WE 101-000-418-ON)
M'F,Si�riu�7.:*9_11CA1, i�'E&�'.�.— POOL101-000-42}1.--/0/00
ft�n
X1X 7 f,�yu..^A1, F.-0& — POOL, 101-000-420-000 0 $45.00
1A6wlwarm ftE.-• Pool, 40*1 t -M, 0-4194000 $27,00
r ? "J°+ AlXONI ` f°SCCA AN T9 PIAN t;`:lVtk-
$407.85
L141101.4 En -PAID PUS
$0.00
AUG - 2 2001
RECEIP.u, w_
DATE r "' ' ? J.._
.BY
DATE FINALED
INSPECTOR
R11
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
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Z?/
Equipment Location
Underground Electric
Underground Plbg. Test
1
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
_
41
Sewer Connection
Encapsulation
_
Gas Piping
_
Gas Test
Appliances
Final
,2 - -v/
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)
Wit",