0202-012 (RPL)U)
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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. Class Exp. Date
614611 0513 03/31M
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.
( ) I have and will maintain workers' compensation insurance, as required by
,.Sfection 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 STAT%I�D3AID Policy No. 36104670/
(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: >. Applicant^ ,r-��'► °-' rc:.�'-
Warning•rFallure to secure orkers"Comnsation coverage is unlawful and
shall supjecf an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building .and Safety
for a permit subject to. the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application.is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon .
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) , r / �'"'•�h'✓Date—�•�
BUILDING PERMIT. PERMITN
DATE ! J VALUATION LOT (')er__012 TRACT
-s
JOB SITE':. . r�� ' _
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S R H I UC
MCNM P001.14 46s WAV
16940 V01 .T10WAN 000
P,01BOX 3791
!RVINE Cyd 02606
'
LAi Qtn11grA CA 92M'
(760>360-358 C!?�:t;9 1945
USE OF PERMIT
POOL A341.) SPA t7NLY":.6<i t�n�klWif3rAr�}:]lE}2S S'k[t3D,]� �fdL.l;Ai �C,�`.'i3 �14lOIi
TO.01kPLASU1I INSIaS`+•CTION. POOL, F`f.�M'Fk�Ii^fid 1 1NtrW9, UUP, w0T
YNCI.LUM 114 l+EMMI F.
I' )(YIJAA31IYOR SNA
R..111.6.9$'in^iTM COST OF 701✓!.`:sMMMsd.dO
M6ii. AN$
P1,4N VJ4ECr,, $'`, . 101.000.439.3118
0ONS9 RUCITIO-N VTZI 10 3 ••hili" I P 000 $163,00
WCHA)i1CAL. FEF„ -- POOL ] MaOOG- 4211.000 $24,00
't1Xt,,'t'i�.,Tc.A.dd .i?'EV, t w PC)OL 1,01-000-420-6100 $45.00
I$I,f iP.4UNG FUl -- Pool, 101.000.419.000 s 7 tin
A` i3��;�i 'a. COM'M'Ea.UCT11C1"I"AND
cz t 1.. 3S PRE -PAID • t .. 0
$0.00
Lf PEM1 111MIRSVO-r- HOW
FEB 06 2002' .a
CIT CIFIAQ✓Uy.
RECEIPT
DATE `
BY .^
DATE FIN
I ECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
'
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I-
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
Sewer Connection
Pool Cover
Encapsulation
_
-/3 J�fjO
Gas Piping
Gas Test
Appliances
_
FinalJ�.rf
2
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COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures 22
Main Serv�Le
Sub Panel.5,
Exterior RE6eptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
,
Final
Utility Notice (Perm)
OW
5A. 42q 50. FT.
.'� SPA X �'
-22 PER. 22'
S.A. 38 50. FT.
- - DECK IOq-7 5G2.FT..
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App VED
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