9806-120 (RPL)1LICENSED CONTRACTOR DECLARATION
under penalty of perjury that I am licensed under provisions of
H I hereby affirm Cht�pizr 9 (commencing with Section 7000) of Division 3 of the Business and
NW Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
1_ W 72.1005
oN X% fi 2C�iCQ
OZ 1 wDa�' �r Signature of Contractor?
r- U �
OWNER -BUILDER DECLARATION
W aLU r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
M () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
a)
Q WORKER'S COMPENSATION DECLARATION
EL
p Z I hereby affirm under penalty of perjury one of the following declarations:
LO - O () 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
(5 Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
coo
d
J (This section need not be completed if the permit valuation is for $100.00 or less).
(X� 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
1 subject to the workers' compens;5ipn�provisions,5�Section 3700 of the Labor
•�•i7 Code, I shall forthwith comply with those provisions.
VDate: Y /.; `�.Applic/� ... - -. `•_
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
thjabove mentioned property for' spectionpurposes. ,
Signature (Owner/Agent)!s��`'•Date�%��-^£%
BUILDINGPERMIT PERMIT# CONTROL#
91it*_1241
DATE VALUATION LOT TRACT 7942
JOB SITE
APN
ADDRESS %455;V18l ROWER
OWNER
z•-
CONTRACTOR / DESIGNER / ENGINEER
11A,'1tfCk 41EALY
' M,f.E Y P001, & SPA
3-445i EI.SENT40WEiR OR
47410 F. PALM CANYON DR_ Y 16
LAQUINTA CA, 9223
PAIM SPRINGS CA 922454
(760)77R-3931) C13Lff 21%5
USE OF PERMIT
d
11001./:;PA. 2W 1117, b' H1 11154 COK, WALL, ALARMSMArRRURS 7� �
511,',11 iW 1dPIERATIONAL ATJsYJ%-IA,A.1 .1'YR, INS14X:1`1C)N, r
JUN 16 1998
WALL. 2W.00 Ll` (
`.�' 1 T
1 0
xsS 011Alfs;CJs:fa,I't3F1'.;ON'XrQIiC:'1`1141
1XI(AHM11)
X11;1�1V6:$`t! i+'�;�,1>1JI1'ft;4j.r'�lt�ti�
PIAN CtIIif"1: FRE 0141
� °rz NR•t� t 1c�•ac1N 4� 1?fs 4 4f 1-�If}...�I y{.�(1fN1 �^ f G ixi
i'llsi~:.I11tJi.G:�1 PTAI 'POOL 101-000,421111 0 vi�b,tltl
f?10.I'1c CAL Il1:;t;— I1047JI1. 10140-4240-000 a•45.i>st
I LIAN 1#INO J fih -- 1°t:M:11. 101•(;414-�t 19-4?#413 $27.(N)
SURI.Y)ff!L CONS4' UC7110N AND PLAN c,M;1:1.'..
x.tflt 60
LESS PR -PAID PEES
T.9 (K)
'1'0*f'A1, PERM IT !+"01 Xi Of IF, iV0W
$405.0
RECEIPT
DATE
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall = Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
POOLS - SPAS
Footings
Main Drain
Bond Beam
Approval to Cover
!�8
Equipment Location
Underground Electric
Underground Pibg. 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 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
l
r
Final
Utility Notice (Perm)
COMMENTS:
too,
441 6• -
63'
R-------25'
AL
&hoa s"
30'
P1 an C Uhreeycter�0
U--7'
VALLEY MOL & SPA.
DESIGN & CONSTRUCTION
474IC E Pais Canyon. Ste ria
Palm spiwg& CN. 0`144
Oriveuay
AV AJW
►4' 6^
17'
,
Y
to, 47'
I�
i V
� G
30' n
so
�Tll
P1 an C Uhreeycter�0
U--7'
VALLEY MOL & SPA.
DESIGN & CONSTRUCTION
474IC E Pais Canyon. Ste ria
Palm spiwg& CN. 0`144
Oriveuay
AV AJW
►4' 6^
17'
,
Y
to, 47'
I�
i V
� G
30' n
so
JI --'re 'A/eAyy
1 1
VALIaT IDOL ! SIA
DOGN a CONMI;C,TION
4741C f lbw C�7�,1 Sit
1 .
paw. S/risss. ff
CDN
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lop
ol
H� r\ •,�„ ,,...,.-a f' • � `• : r�o n dry "`,:' n: it;� r
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SU LJ E- C,
to ANDLL `'ECIC;; Co
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BY_-
JUM-15-98 06:07 AM NHF CASTORENA 760 772 5860 P-02
S il'lO .
CITY OF LA QUINTA
coNTRACTOR VALLEY POOL i SPA _ ADDpn 4741C E. PALM CANYON OR 0116.
OWNER MIKE MICKEY SOS ADDRESS 78733 NAPLES
AM DIG&JUJULOW.
This form shall a M vdth " -nefing Intimation Cud at 19 Ibn In a —
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub-eontrectors that
are on this list are the same persons perforrning the work. Any changes to this Got must be approved the
City of La Quints Department of Building & Safety optu to work being performed by a Changed sub-
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit,
TRADE
. .. I
SUOVOUMCTOWA
NAME
TY" OF
LIC9m
STATE.* " ;. .. .lN06W6
CONTRACto m
UCM .. ,
�INIMriNt
I
COMM.11mv
MUM.PR ON FILE
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