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0203-401 (RPL)Cn H N to W Ouch d u7 ' W ~o Z � OO H� W LU �a En Z co LO N ON _U °' d Z r 0 0 J J 120 _J fl rn H ,'I- Z co ::) rC) Q J 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. Class Exp. Date �1> 4 C-53 "~�\ 10/3112c r Date '^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: ( ) 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 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. (se) 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 STATE MIND Policy No. 1034803-01 (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 sub1ect to the workers' compensation provisions of Section 3700 of the Labor Cao• de, I shall f rAh[4th comply with those provisions.L bate: �' .,:,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 pursuan6o 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 - ui jding construction, and hereby authorize representatives of this City to-ent r_upon the above-mentioned propertyi for inspection,purposes. Signature (Owner/Agent] '-'�^U-� Date BUILDING PERMIT PERMIT# DATE r r VALUATION LOT ; t:� TRACT JOB SITE APN ADDRESS 7 Zvi.w f Y D 1� _ OWNER CONTRACTOR / DESIGNER / EN (NEER Ma ,mo q N AEuSt:3:ISCAN POOL COMM. UMMON 18.870 GALAXY Dr%M, 73960 MGHVdAY 1)1, ,AQUd'�TA. CA 92253 ) Ij•.}�;Ir��RSd%��Ff9.M' C�588 ,.�y7�9 `�7255-9ry� USE OF PERMIT : OUL AWWOR SPA. POOL.AN11 SPA C?id>aY'. AirAitM-WliAI,C PRS SHAIX HE IN PLACE PRIOR TO PRE PLASTER R?8VECT1014, POOL. FQfJ.)!'M VT ENCLOSURE', I -JOT 114CLUDED YIN PERMIT. fk)OLANIXO , SPP,, 2ZO00.00 L8 4XILIV.) COST OF COWILIMMUC17.0w ]VIEMMIT FrE WOMMAi Y )ALM CHECK FEE 101.000-X1.39.3, 18 $146,25 CONSTRUCTION VEX 101-000-418-000 $225-015 M1<:t:'1•i., LAICAL FEI.. -- POOL 101-000.421.00 $2.1.00 EL?r.'Y'ATCAL I 1 - POOL 101.000-420.000 $,15.00 r LUM..011110 FRE PAVI L 101-000-419-000 00.419.000 •� LZ 1 $467.23 _ : i LE3S PRE -PAW VJM $Q. D© APP 1 12092 FEMMMS IM C9 lOFLA►��1i� �a . RECEIPT DA/TE Bey'" � DATE FINALED INSPECTOR 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 Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS steel el -/o —� Set Backs Electric Bond Footings Main Drain —e'oV —Z— ZBond BondBeam Approval to Cover -zgi Equipment Location Underground Electric —ld —t Underground Plbg. Test Mal Gas Piping PLUMBING APPROVALS Gas Test Electric Final Wast- e 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 Gas Piping _ Encapsulation Gas Test Appliances _ Final y 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) COMMENTS: CITY OF IA QlJINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE (i /OZ BY k t t PERT LINIU UTE[TY POLE J� .i1CT4N BOO( RDSE as � S10WER � DECI(O'O _ttY EASEMENT V� ELEC. PAWL ® BLOWER --- £LL LME �4 L13HT Q AREA DRA IN CE 0f*HT, TYPE WAS METER O 1ARTEP LEVELER FO FLTER —+ DFI RETURN PVC OgA�i RGfKXM ELECQlQv! ERGROIR� V BEN MAW � FAEMRDTE YkLV•E 0 FEATER —+ TFffRAPY GRAB RAILS WAS RFEAD ELEC. ® VWATER DEPTH ® GATE 1ALVE M AM DRAW --4 AERATOR LADDER AHEAD TELE RAL' � SWITCH � P TRAP C::, KW GAS GRILL C PEDESTAL ACCESSC> 0 IREDEPTACLE ---a SM & CUPANDCR SEE NOTES NOTES: 33 ' AREA MAP ` m w f -+N N CD CD N CD LD N m A LO A w 00 XEr Baa No. t CLIC.*' 518712 _, 1 LOT Km roc SELF. mu ... aMe��caK D ��� ft)N"TE'1)CT1C1 m .80X 11996 PA �OESERT CA. m" (760) 340-2588