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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
6188,92 wd) ,M4
Date '� %J -J Signature of Contractor r �y �'�'-��'
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
() 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 is issued. My workers' compensation insurance carrier & policy no. are:
Carrier MAMMON R43. Policy No. 05KR000901
(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 orthwith comply with„those,provisigns:- ,,,� 00
Applicant
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 iso
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 upori
the above-mentioned property for inspection purposes.-,,-"
I ignature (Owner/AgeQt) --M� -x ' -�<' Date
I _.'
""BUILDING PERMIT
PERMIT#
DATE VALUATION LOT (002426 TRACT -
JOB SITE r APN
ADDRESS 52-1 USWSKWHOWER DMVE,-
OWNER CONTRACTOR / DESIGNER / ENGINEER
MX E4Tid7J/OR MRS. C"ONAWAY
LA QiT3ATrA C:R
USE OF PERMIT
POOL AWWOR, SPA
BLMHAVIM POOLS
2318 $ VD%TEYAIW AMMY, SUM, A
92.253 Ol+f 1_'MUO C. -91761
(909)D47-6474 Mliffi 5240
PC53." VSPAr ALAPM"APtFtIMS SH -AJ L RZ R4 PLACE AT f'.R&P"r<.ASTYR '
:WSPECTI N. FQUI.P1491 f 1�'t�MSURA? WT IgG1. UDE, D
E'00?11,MIDJOR SPA
19,00.00 ')
MM -0m VIOST OF COMMUC1110N
FgRwr vim 5� RY
PLAN QJXC FEPP11 101f-000-43,9418 HUM
CON,MT-ttC t 1014 DEE 141.000-4.18.000 $198.00
ME i..ANIcAL Irk'k •- POO!, '103!,000.42'1000 _ $2111,0
ELPCTIUCAL F`F9 ad POOL, 101-000-42"00 "00 $45:00
P U1/i 1�M n R •- POOL 101,000.419,000 $27.00
�[i1 -'Ct 't��Ai . Ci T k17tr IC? J 3IS 1.�1 T Fi C:i $42230
D USS SS PRE -PAID :P -S $0.00
,F FEB 1 g 2003 0FA1,:P `117-AND1111;i�iOW a m
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT DATE i BY DAT FINAL
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 ;So
Set Backs
Electric Bond r K
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 (Gas)
ELECTRICAL
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)
APPROVALS
COMMENTS:
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