0403-310 (RPL)U)
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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.
Licens j i„�.^3 tsi Exp.
JaJpft7:4
X``�;De,. Signature of Contractor
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OWNER -BUILDER 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 employeewith 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,is�sued. IMLyrw9kers' compensation insurance ca�rr4ey4 policy no. are:
Carrier Policy No.
(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, Ijshall forthwith comply with those provisions.
/bate:. �, 7 ,) Applicant 1
Warning: Failure to secure Workers' Compensation cove rage-is'iinawfuI and
shall subject an employer to criminal penalties and civil•fi s up to $100,000, in
addition to the cost of compensation, damages as,provided, for in
of the Labor Code, interest and attorney's fees 6
IMPORTANT Application is hereby made to the Director of Buildi D d Safety
for a permit subject to the conditions and restrictions set rt onA�fsO
application. II••''F1�
1. Each person upon whose behalf this application is made & e ch ers
whose request and for whose benefit work is performed under r pursua* ttg AF
any permit issued as a result of this applicaton agrees to, & sh II
& 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-forinspection purposes.
/Sig"nature (Owner/Agent) Date
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BUILDING PERMIT PERMIT#
0403-31.0DATE
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A �VALUA ION i�66•0(� LOT TRACT
JOB SITE
APN - -
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
J01 HARVE r
lm.Ims01JO01. Tful mBJWG, lgc
78.243 DM,'I T F'AUZ WAY
667 EZlGaM i2D1
U. QUOrl- . CA 9225.3
PAISi4 S14GR CA 922641
(760)327-7592 =0 .816
USE 9FEyRLM/ IIWlO�'t 91)A
SAhl
t . AgIDA V)%JJ,V Al P!?RAR PP11'�11-+c!NM
.t F49 2N) G'T. rIrvy)mR in
Pi3EPLASTER INSPECTION,
P(XC L,AHD OR SPA AMIN W
PIUM7' FIS t SC7.t!/3.IViARY
PWI CHECK FEE 101-000-439-318 $172.25
C:ON;'sdRUCTION3 FE9 401-000-418.000 aabS.E10
I+llNANbCAL RE 01.000.421 _000
MECHANICAL Vi("I?;.- POOL, 101-000-421-000 $a4.1,50
ELKI C'TRICA.L ME --POOL 1011.1100.420.000 50,00
Pi."IJ.ti,4B14, '9 FIZZ - POOL 101-000-419-000 $17.00
3 2004
"(W'_ TOTAL CON'SMUCUMT PND PLAN CrMIX
X53:1.25
LA QUINTA LESS S PRnT^PW1 Ims
$0100
CE DEPT.
TOT'AI, P.1': IRMI' T :Ei'Q£11:S :1311;31 OW
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RECEIPT
DATE
BY f—,
DAT ' INALE
INSPECT
/ / /d
ool ✓
INSPEdTION 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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
1,
Equipment Location
Underground Electric
Underground Plbg. Test
Fina)
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
.Z
Gas Test
Appliances
Final
-
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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)
03/22/2004 08:14 1784920' GATTUSO FOOL CORPORT PAGE 02
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