0201-214 (RPL)LICENSED CONTRACTOR DECLARATION
" 'uj --,Lghereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c4 W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
P4 IL C33 0:1 llp,(
6 Z ti
O ! Date Signature of Contractor
O
(- � `
J U OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z ( ) 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).
ce) ( ) I am exempt under Section , B&P.C. for this reason
O C9 Date Signature of Owner
..........
rn
2< WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Hp () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q L) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
li �H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z CarrierPolicy No.
ob ry5 STA' E%'i3E�O 1dii ZEv7pE
V
J (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
IVACode, I shall fortfi)With comply with thoa provisions.
Date: A vlU Applicant. "+r •
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.
1 -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.
t Signature (Owner/Agent)p.y'BS DateI?� 1
i T4 �—
BUILDING PERMIT PERMITN
DATE VALUATION LOT' �'� TRACT
$154")M 16 ;c�381�1
JOB SITE
ADDRESS 81-270 GOLF "VIEW DRIVE
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
: ital, uC
MSC323'ii RE, POOLS & KI'AS
} 694.0 V"O-ISI XAMSLAN A`rL, :Y1S 100
P.O.31tQx 1791
MWE? Cry, 92606
.I.A.QI.T..WA CA .92133
060""360-3585 QW i. 1945
USE OF PERMIT
POOL ANNOR MA
POOL, AND SPA, %DN1,Y. ALARMSIBARZA1931S SPIUVJ. BE, IN l I.A(* PRIOR
TO PREPLcRST'E R ilNOPOCTION,-
POOLArdE.3 OR SPA 00 LS
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CONS'���?,��i„.' ION FIM. 1011 000418"000
MIrMIMC 1 1IFFI1,•..s P'0011 101-0i904-21" 000 U9. 0
ZGI,� d'ictt 11% - POOL 101-000-420-000 P9.S.00
E5 WADfAtO MWE - E'OOi, 101.000.419-000 MAO
t"
SVIE-ITMAL AM) PLAN CJ-J7FrX
$363.30
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M .� s ��"NOW
1 13
7�JAfd 2 2002,Pr
r f
CITY OFLAOU147r,
RECEIPT
DATE s
BY'
DATFF,r
PEtTOR
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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
q
$ /�
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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:
1156 SG.FT.
t)t"A l' A -1,
PER. 'W.
S.A. 44 90. FT.
DECK 1804 9G.FT.
2 y��/s
0T he
BUILDING &
APPROVED
FOR CONSTRUCTION
m.%-rg= I g4-0 2- .