9703-034 (RPL)U)
N w
O D CD
/C) L0
n W T
Apr
T
W W
H Il
W
Z
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
7•,_Chap jjr 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 '
i i°SI? i r1A k*3iA)
/Date � � Signature of Contractor �•,,_.., �a �'��"�
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 (Sec. 7044, Business & Professionals Code).
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 issued. My workers' compensation insurance carrier. & policy, no. are:
Carrier Policy No..
STil-VIIE t'+UND 24°?r3;9-96
(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
su,Pject to the workers' compensation provisions of Section3
00 of the Labor
Pode,J shall forthwith comply with t ose provisions
VDate:12 ;L 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
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/ior�, inspection pur ose
sr �
Signature (Owner/Agent) .L�la �� Date
BUILDING PERMIT PERMIT# °°NTR°`"
v � .�►s3 4795
DATE VALUATIONLOT TRACT
JOB SITE
ADDRESS 45.090 .ii EMNT SANDS CT �
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1 Q
4: , ,,J.
F.I`1.i r
tpF
T
�_��tOOT C0T��R,'c7N
.l'q1713.�
1'.Tt
13-011 .OUNlXY CLUB ORIVE,7 7 . F4
SAN HERVAR.l:►1NO CA 924108
PA1.M DESERT CA 92200
(6 11 0.t,11164032 032 CAV41 1.0A4
USE OF PERMIT
VOOL tVN-b 8.0ik 0 N L Y
POOL rlNIAtOR SPA I ry,500,00 LS
f4NMIT FOa�:;SU;wMARY
101.ONA39•-31€3 311.1.15
c��rf� r.1t4IC'1`1��Rf r• ��; .. s t) �.-c�f�a-:a � �-�r.� s � ; f ,gym
TN C'HANfl'CUV IFTEE -- "frOOL 10:1.-001)-421-000
EL, 1-C1IUCA .-`fid.101-W0420-CM " �a�.c►u
m.<i ,mlm-Na;T; t-- w:Km_ 101-OW419-000 $270)
01 Af'
' -'l EA_L CQN�ll 'OC; -NON AND PLAv
$378.15
e CESS 'IT\.F-PAID FEB
!�
'iQ)TA]::$'1~;1t1V1!_!7"f)'ERS DUE'Nf34'!r
RECEIPT
DATE
BY
DATE FINALED
-
INSPECTOR
INSPECTOON RECORD
OPERATION DATE' INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wail Insulation
Party Wail Firewall
Exterior Lath
nnwmll _ Int I nth
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
PLUMBING APPROVALS
I Shower Pans
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.'
Smoke Detectors
Temo..Use of Power
Final
Utility Notice
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground' Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Gas Test
EM anal
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover.
COMMENTS:
POOLS - SPAS