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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 # Lic. Cass Exp. Date
672850 CJ�3 �fV W30103
'Date Signature of Contractor-
-- 3< -
OWNER -BUILDER
-
OWNER-BUILDER D
I hereby affirm under penalty of perjury that I am ke !21pPfrom 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).
( ) 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 Sianature 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. 3.613074.02
(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
,Po'de, I shall forthwith comply wltNthose provisions.
(Date: tF,"�. Applicant—
Warning: Failure to secure Workers' Compensat'Ioficoverage 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 for inspection purposes.
Signature (Owner/Agen1t`:_5 �� Date It
BUILDING PERMIT PERMITk
DATE "NLOT tS%^71��i TRACT
'��" VALITATION
7
JOB SITE
ADDRESS 51..970AW.AMA.D
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
DAIV . S'f°Ct ttvKU.0- 's
OATruso Poul, In'XE.al RING, rmc
LA. CjaactA G,4A 92253
NU&I SPRIT08 CA 922&
(160)327.7592 CTIA 016
USE OF PERMIT ;•
P't:00:L.AAt'i OR +PA
PIDO dSP.Fi A1,,.ApEM5,113AYMR0 SHALL BE, leaf MACE AN P1,'& LA.3*rF.,R
P001, ANUOR SSP. l fiiil►.SYII.1s5
,
IPFUMIT EE S`Ir3`M WRY
Pid',1`F CHWX R'm 1.01-M-43.9-316 9.316 812:2.'0+
M;- 11-Itg'.I`n�y.,tUCNkl'1O,�2N PRE 101--iPZc�4R�aiel�1fe••!oa(I $2ii�;tii1
.
MECHANICAL AL. G"EE -- POOL 101.0m"-9.23-clo.� $24,0
ELECTRICAL REP. — POOL '10"L -000-42o-000 $45.00
P1.rt.1.I BF1140 PFT .. Pool" 101-'000-419-000 SZ499
A
AND 1'.1-0114 C11T IMINN
'XXY_rAL. P. TR M3t'2"T+. -k,03 Wim` IN OW
%" SEP 30 2002
"
LA T.
CITYFINANCE
DEPOF
5
RECEIPT
DATE
D
INSPECT R
v2
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
,/p -
Set Backs
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
_c
Gas Test
Appliances
Final
— /
COMMENTS:
s
t
Final
4Jtility 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)
FEE OF
p RE-INSPECT101� THE APPROVED
WILL BE CHARGED
PLANS AND )OB CARD ARE NOS
THE SITE FOR
INSPECTION. TIONS!
.NO EXC
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FR�t WTTUSO POOL CORE' FAX N0. : 75077844-50 Sep. 4 2092 Ot:27PM Pl
Cooperative Red Imported Fire Ant Project
Notifleatyon of Intent t-) Move Soil from or within Quarantined
Areas of Orange, Ptiverside, and Los Angeles Counties
iiIFA Cortnptiance Agreemen t JZ= 21' Pc"m't
Issuing City/County
Agency
Flame of Company Requcsting Approval:
Contact Person:
Address: �j r City . �' MA �� .dip:.. '
Telephone: �t ' Fay;:
FAaaystion Location: 5 R ]2)
Estimated Quantity of Soil (e.g. -0 Cubic Yards):
Anticipated nate of Movcmcnt:.._
Urgency Levet for Immediate Enspeetioa
r
Movement of Soil iS Penr;itted.
ACRES:
Med'►nm Low
Hold. Movement Until Sit: Checked • WE WILL CALL AS SOON AS POSSIBLE TO
SCHEDULE INSPECTION DA rE AND TIME. \'
Dace Trapped: t$ �f Traps: Trapped bAcres:��
Date Picked Up: CoszimentG DR #:
Soil Movement is Strictly Prohibited for the Following Reason(s):
fi18zz18 OF RIFA pfOjCCt RCgulato Official: ld
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