0311-216 (RPL)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
•8j3469 C53 _X30/05
Datei�A?/ 1 - 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit isi$sued. My workers' compensation insurance carrier & policy no. are:
Carrier 1•.XlNIPT 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,
lishall 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 provlsidns of Section 3700 of the Labor
Code, I shallrforthwit� comply with th se•provisions.
Date: 11/7 Applicant % Z
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.
. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant un
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void 'f
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for .180 days will subject permit to cancellati
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 buildi
construction; and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes._
Signa ut re (Owner/Agent),/
PERMIT #
BUILDING -PERMIT Dill -x•16
DATE ,}�t. VALUATIONjOB EP«I�TJ 971 LOT TRACT
APN
ADDRESS��°
OWNER
CONTRACTOR 1NEEE�R
O7S L,7*+NCVL
y/pDESIGNER
.<�/PEN
L'Fa .A'lt?LVk c V1.rvC:lYJi.t6V L¢i 7®.�f
80.8S11Hi:M.TAGE,
66705 C'"W? MUM
Z.A. Qi711,1' A CA. 5x22;:3
UM3ER1' HaT MRCli G,1 CA 9 -2240 -
-2240 -
USE
USE OF PERMIT
POOL MWOR 'SPA
nhrN Sr»a Irl NY6%9Q .tJ £!!hi`i V LJ l:lf f '1C o )i A'
Y]1 fr Y YYi n
ell 'Y S T•A8iDAPi1 FIREPIT (496AIJAL) ,ALkRM8/1MRR1Er13 3HAUL .BY,
IN PLACE AT PR&PLASTER 1NSPEVIO t ION.
4 F.. 'WALL 28,00 LF
POOL..P.3JVOR SPA 3:? 552.00 1.5
EMINN011-; COST OF CON s'.gUMC'3' DAN
1'Rkhar fi';m f3"€livE"tiny
MAN CTIECK ,FEE 101-000439,-31,9 $.201.83
CONSTRUCTION z:�%y�,.q�y,t 101..t•?00-418-000 $5110.150
�CAtp3nl{��t��(�:9TRUrPC�Tw1Yi
MrEC11%�:M'44k.YTlt.i'�ii-•.`'l.OL! 101-000-421-000 Y. .00
ELECTRICAL PEE — POOL 101-00- 420%.000 W.60
PLuP5TAGIFE-.POOL 101-000-419-000
SU-C3-:170TAL CONS MLTMON AIM 1 I`�T CHECK
$406,3
n ]LE, S PRB-,PAS Z70,0
$011.111
'WTAL �1r'.�+:l1 IT .€ ESS -0f1 NOW
$W333
DEC 2 9 2003
CITY OF LA LIUINTA
FINANCE DEPT.
RECEIPT
ATE i� 1� j
BY'�
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location loo
Underground Electric
Underground Plbg. Test
Final
Gas Piping
j, PLUMBING APPROVALS
(
Gas Test
Electric Final
Wastab Lines
Heater Final
Wate�-?iping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
;�ewer Lateral
Pool Cover
Seaver Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
UU14 Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
0
.tet ter. uuuV I H ,Ub-UUIV I H . U 1 UH LIST
JOB ADDRESS Q U 0 `l I f'."t n'tr`f�� �J PERMIT NUMBER OWNER AU -SC -41 I6"i C BUILDER
Zhis form shall be posted on the job with the BuildingI> spection Card at all times in a consoicuot_rt place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade I Classification
Contractor
State Contractor's License
Workers Compensation Insurance
Company Name
Classification
le.g. A. B, C-8)
License Number
Ixxxxxxl
Exp. Date
ixxlxxlxx)
Carrier Name
(e.g. State Fund, Calcomp)
Policy Number I
IFormat Varies) I
EARTHWORK IC -12)
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A
tjCZ)C' 7
121 ;1 (�
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i11G GC. 0 SI L
IVr
CONCRETE IC -81
�iCltJt?4(CECCr�'Ia.f( i`-1 lrjui
G-�
7tiiCC(o
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> }�S U Z
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STRUCT. STEEL IC -51)
MASONRY (C-29)
+a
-Dl-Ii11Aq�.��lrn •. ,..
1✓— —i
,^
V— ,G :17
LATH, PLASTER (C-35)
Pt', �i<.t
-`. : rcz.r't
, u
1 77
_
9► I
HVAC IC -201
ELECTRICAL (C-101
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING IC -171
INSULATION (C-2)
SEWAGE DISP. (C-42)
PAINTING (C-331
CERAMIC TILE (C-541
CABINETS (C-61
FENCING (C-13)
LANDSCAPING IC -271
POOL 1C-531
e'VI
I City Business License
xp. Date License Number ' Exp. Date
txfxxrxx► lxxxxl (xxlxxlxxl
L L G`I
%1 104 1 AJ -a A 5 B• 11, N