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0011-102 (RPL)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I amlicensed 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 471587 E A, � 09! 3t31�C 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 & Profersionals 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&RC. 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. (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, I shall forthwith comply with those provisions. Date: • �'�- Jli Applicant—* .n [" fel 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 for inspection purposes. Signature (Owner/Agent)_ Date ='BUILDING PERMIT PERMITN DATE —^� VALUATION LOT ••'�-TRACT :1 i $20,159M JOB SITE APN ADDRESS 88-140 CK31r i V1E`W IiEr°MI. - OWNER CONTRACTOR / DESIGNER / ENGINEER MM. ALB A1+11~S'K: SEAW M. Di,IFY'Y.'dba 31111M SAMH POOLS 8).140 GOU' VISW MWE 74654 VE1,JSWAY SU'!TY 7 LA Q1TMTA CA 92253 PA&M UF8ERT CA 92260 (76tfj341.0117 C M44 -6211. USE OF PERMIT POOL A14TYOR 8Plk .P001. & SPA C'CNLY•Al-ARM.s"It7/yX1:.i9PS S!'.'A).,L Rit 64 Pi-hi:IS AT PRE R.A31'1 R URSP..WTIO2^1, MIL AQtiii�;'r EAT ENCLOSURE RE IS WOT 1140 LUDRD IN T11131"RRMIT POOL, ANWOF,SP* 101iai1,4t0 iii k X&M!1 1*111, COS"' ' ADX+' CO.R.6— c"IX7.' 10H 201150.00 PLAN C1WK; r1✓: ' 101.000.439.318 $140,40 C:C)AI:;Y'fi.u6.`•TICY s F91C 1011-0001.418-000 $21 .00 MEC'RANKIAL kUR --' POOH, 101-000-421-00.0 W,00 XC ='TR'1GA"t, iYUP,, . POOL 101 -000.4210-000 � 1Fsh5.lN3 PL1t1�1�IA�l�1 P1Af'� •-1'Of�ls 1014"419-000 -A I NOV 17200' AT Y ur LA c uINI k STM -T AL C646'rkUC'f ION AND P7,.AN C .Me, $452.40 LT? 33 .PRE -$!'AIG F510 50.00 TO'C'.�ol.ITIR"11.1 Yns JAM Now ��•,� l`rH RECEIPT DATE By -f DATE FINALED INSPECTOR n W 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 Set Backs POOLS - SPAS steel 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 Final Utility Notice (Ga's) 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: 6' spa +18' 12' Line Eq CITY OF LA OUINTA ARE-l"PECTION Ff BUILDING & SAFETY DEPT. 1 p CHARGED IFTHEE OF $30 APPROVED + TNENS AND 1pB CA APPROVEO r ON FOR CONSTRUCTION r 11VSPECTIp" r '� C9 1 NO c(CEP 1414T ME By I Awa 425' PropertyL' efthoda 93 )erty Line _ 7' aa& of I= �h +18'r— +18' Plarbe�ahi�e �) S' 3' Stacked quartzite 3 5'6 " IAuWfM YES pia Residence William Albanese Residence ,�qo 6�1 F�ev�i2 PT F� Equipment Block walls stucco to match house - X20 R c CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California ss. County of c ���t_C:t� On ` U Ubefore me, l' > U l �J n D to Name and Tiof Officer (e. a e, Notary Public") /1 � i-. personally appeared a personally known to me proved to me on the basis of satisfactory evidence to be the erson �' whose a , subscribed to the within instrument and acknowledged to me tha hE /"e�/ #Sey executed the same in is I�/tl &authorized ca aclt i'ars, an that b h'' Kee it �..a ure'on the instrument th erso �or e—e t y upon behalf of which t o perso acted, executed the instrument. WITNESS my hand and official seal. H Place Notary Seal Above Signal r of Notary Public OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document: Document Date: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer Signer's Name: ❑ Individual ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Number of Pages: RIGHT THUMBPRINT OF SIGNER © 1997 National Notary Association - 9350 De Solo Ave., P.O. Box 2402 • Chatsworth, CA 91313-2402 Prod. No. 5907 Reorder: Call Toll -Free 1-800-876-6827