0112-049 (RPL)1�-
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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 # 7 Lic.. CCllaps�s•� Exp. Date
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Date, .M� r 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:
( ) 1, 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_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 a"? �iZ COMPRMATI Policy No. 0460 6108
(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 those°/isio ,vim
Date: w.." Applicant—
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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 f99 inspection purposes.
Signature (Owner/Agent)404, i' eA Date/0- Ul
BUILDING. PERMIT PERMIT#
DATE � VALUATI iN LOT 0112-049 TRACT
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ADDRESS I(PDAMM8.ON 9.MM
OWNER
CONTRACTOR/DESIGNER/ENGINEER
f;M'44ZL�T.RY, C:��zC�ipW� EIL C0�j M111 172
P'gU1 iOU r% :3�a• M (10P MAW t-01
1 � NOa D" 9t TR.L':fi^.ry �J�, ;i`200
+(y°14ry�.pVL�I��ytt�`,
I"� 25 eYO1,�Lf..L.IUVEa �J7Y.S�:#..'�.
SAW 33:1:'1Mf+RIM19 ^ CA 92408 08
:k77ALAM DM,R7' CA. 92.260
itiswvvElS'e:J
('760)340-9000 CIBLO (1035 5
USE OF PERMIT
POOL AND/OR SPA
PDOUSPA. ,ALA1rtMS9Pf APPJER.5, SN.AU1, BY, 114 PL,.R,.0 AT PmPLA."`Fim
I1 tf 1dF:�; t'iG)1`F POOL
POO1. ANMR BRA 174500.00 LS
;PR cMTED COST OF C:OM?t'9.d1:-K-MON
77�"i4}D..i�fi3
TILAN CHECK Fa •10).000-439418
C-01NS'TFLiXTIOWME 101•^000-418-000 �189.00i
MiEtv%iJbNItCAL ME .. POOL 101.000,421.000 $200
21,.15C: TTWf L �'}3X.- POO), 101-•00' .420�+4�0
pilutff p,4) FEE . POOL 101.000-414,400 S't.` go
DEC 07 2001
Cf YOFLAOUWA
�X,_SSDR TI CM -M
$407,85
q93S 'PRE-PAND M70
$0.00
.. TOTAL TAT P -12M iLITS DUE B0 41
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RECEIPT
DATE { J
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BY r'!
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D&E FINALED
INSPECTOR
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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'lnsulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
steel
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Electric Bond
Footings
Bond Beam
Main Drain
Approval to Cover
/A
Equipment Location
Underground Electric
Final
Underground Plbg. Test
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
---oyer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)