0308-320 (RPL)F]
LICENSED CONTRACTOR DECLARATION
,I•he'reby 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
61.8892. C'53 HIO OSr3•117t..
Date nature of Contract]+'^
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 orofferedfor
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'SCOMPENSATION 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 C:I..Ai2.MON INS. Policy No. 06KR0000891
(This section need not be completed if the permit valuation is for $10 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.
w
gate:•"'• /1,. ii"T Applicant-.,.^"'—.._.-.-�,�.c-
Warning: Failure to secure46rkers' 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) - -"=="=,r' Date''`��'
f;
{ .,-BUILDING PERMIT PERMIT p
1
ib3C>:3 �3'Q}
DATE C VALUATION LOT TRACT
JOB SITE
APN
ADDRESS • g -W NEST I1AItI�A3dD
-
OWNER Y
CONTRACTOR / DESIGNER 7 EN (NEER
3titk iTtE•?
B1AM f1A'+►'EN P-00LIS
78.840 W. HAJ�T.AND
2318 S. '�Til�'& ARD A'VI:� R F, SUIT A
u, Q¢ 1NTA ISA 922:53
CtNTAR(C) C.& 9116,
11909)447-6474 cMW 52,40
USE OF PERMIT
POOL AWVOR BPA
7OOUSPA, ALA.fLPdIMARRIERS SHALL BE IN PLACE PRIOR To
PRE•g+LAXER MSPECUON
P001, ANIXOR SPA twOi'Ig:OO US
"iTp#ffATKI) COST'OF C0.i!vT.%Y73A1C'iTION
I ,L t1ADlS
i°FAWUT FE; SULV JIQiEiY
P11AN CHECK i''E-E 101-000.439-31 g 1193.00
CONSTRUCTION FEE '101 -000 -418 -OCU $14111.00
]ARCI3,A ICA1. FFR •• POOL 101-000-421.000
91—A TRIC AL FEE •• 113001L• _ '101-:000-420-000 �d5.00
PLUMB1NO FEE POOL 101 -000,419-000 MOD
SEP 16 2003
CITY OF LA QUINTA
FINANCE DEPT. _
SUB.-T(WALr"0 FRUC'11 .AKOI:tI CK.
X3:33.Vii)
IESS PRE -PAM :ITIS
MOO
Z."�* AO
RECEIPT
DATEBY
D FIIIAL IN
PECTOR -'
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
Exteriof'Lath
DrIwall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS a SPAS
Steel 'e
Set Backs
Electric Bond
Footings
Main Drain WW
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 Parts
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
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)
COMMENT'S: