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r 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
P;ofessionals Code, and my License is in full force and effect.
License # Lic. Class 1 Exp: Date
743118. 21 C8 -:�J % � j j /11/30/7C
date �Z '1 - I `"''''Signature of Contractor ) 1 �'
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 employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Seca 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.
S`��j I have and will maintain workers' compensation insurance, as required by
ection 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.
STATE FUND Ii IMOM
(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, agred that if I, should become
late:
ly
�ect to the workers' compensattion provlsaons of Siectiotn 3700 of the Labor
de, Ihll forthth comply with those proisions,j JJ `'U 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'�t
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 withlall City, and State laws relating to the building
consjtuction, and hereby authorize rjepresentatives of his City to enter uporij
the bove-mentioned property for inspection purpose§; h
f
Signature (Owner/Agent) l� s i Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT W11.1-294 TRACT
1,�Kf1�3ffiC SLOWS
JOB SITE
ADDRESS
APN
}
OWNER
CONTRACTOR/DESIGNER/ENGINEER
FUME, T,iAC4A
C.V. OU1` WE
45.090x�.GM`�inZT IMAX IOT.
45.240 PALM 9f.
I.,& QTiWA CA 92253
DTOIO ("A 92201
(760)333.3174 MIX, .4998
,
USE.OF PERMIT
M&RAL la'IJIMII. G
53 I✓..F. OFY € ZTAIN,i'NO tiV.A'ZA,, CITY :"iAI DARD
I FT. WA A, 3. LF
WRLWATM COST OF MH
CO1vM.UCTIONRE 103.000-4l 000
MJB-TMAL CONOTRtcxMON' AND PLM CHECK
T129.00
PAID
DEC 012000 `CYTS G YXIMU ITEM P11: NOW
.%IT`Y uI-LAQUINT
RECEIPT
DAT` •ti V ate"
BY( ,r r
DATE FINALED
INSPECTOR
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Sit 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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
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)
P.O. Box 1504
78-495 CALLE TAMPICO (760) •777-7000
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7101
1E
December 15, 2000
C.V. GUNITE
43306 Wildrose Street
Indio, Ca 92201
Dear: Business Owner
Your check #2068 for $79.00 has been returned to the City of La Quinta marked "Insufficient
Funds" by our bank. Please remit payment by January 2, 200:. If payment is not received by
this date, this matter will be turned over the Riverside County District Attorney Office. If you
have any questions please call Missy Mendoza or myself, Thank you.
Sincerely,
�J DL
John Falconer
Finance Director �,L
cc: Tom Hartung, Building & Safety Director " 1
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RECEIPT City of La Quints, 78-495 Calle Tampico, P.O. Bo 1504, La Ouinta CA 92253
RECEIVED FROM �a v
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ADDRESS ��