0401-268 (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. _;b_
License # Lic. Class Ezp. Date,
Date Signature of Contracto ,
OWNER -BUILDER DECLARATION j
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: yxx
( ) 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 is issued. My workers' compensation insurance carrier & policy no. are:
CarrierS�, E C101M PEN SLATy Policy No. pgt� ¢!b$-�tiffi4
(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 fog 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. *-
A
Date: i..'7n r Li Applicant s ..`Z8 %
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. jN
4 F Y 1
IMPORTANT Application is hereby made to the Director of Building andSafety
for a permit subject to the conditions and restrictions set forthi 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 applicator agrees to, & shall ,indemnify,
& hold harmless the City of La Quinta,' its officers; agents and ein' ployees.
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
lrlinspectionnn purposes.
Si nature" Owner/A ent ,�21F%Date
ERMIT"
` BUILDING PERMIT • P0404-269
DATE
) VALUATION N !1 i�- tt ��ttny LOT O�L� TRACT
)
JOB SITE-,
ADDRESS 49-30f VU CONQIJTNTAD
APN
OWNER`S
CONNTT'RACTOR/DESIGNER /EN (NEER ;?R
't{� •,T'
�i�'y '��1y1 � P'y�t:+; 7�a j ��''`r � �7,
SD D.I.+1.7S.oRP L7'�'.� �' ii.{I..N7r.L'C EN r
✓ y �{'�' �'} ^-t]�,`j'r`p y� �^� r �{ �•'�(j p S {�, �, 2' j� ��Ys �Y('•
�:�'13.11.COJ.6'i.{VdJ1c.iCV.fy.r�7 r..7L 4�.L .l�T.i.� �Vn., &Y1S'+flV 4.L.
PO BOX 1716
86.1(10 l�n��S�TF71 � 5s1
LA Quwm CA. 92253
w� 3AMMU A CA 92236 ;
(760)398.9222 mto 0033.5
,
USE OF PERMIT
,POOL MD/Or
Q (fK S�qq£��Zp7..2j1-Sic-1e9••9y�gl�,eri'IR (406y``1[,�C'}y{4,rL)
PppOOf//.��lg5Sppi���,,A��
j�'PIT
6n1F3���'{{ (� + ¢y ((q�q`�/Vt( j}�q
P9e.v').17�V113Ji]'.Y�RRI Ent i],Tl_4�1ULRE IN, RACE AT PRE-o-i?dt✓'t�Sdr1�•a:+.YF4{ AVfdE-i+iulION.
EQUIP1!?il NT 1V1C:I.OSf'1RE NOT 1A3CLLTi3 ED
Pool, ANDIOR SPA Do W
PL" C'I.6ECK FEE 103'-000.439-318 $%2Oo
CON.SITRUC TI N PEE 101-000.418-000 $tg01.00
MECMRIC All FFS11-- POOL • 101X000-421-000
POOL. 101.000-420.000 $45.00
PLUMB1110 VEYK Me 'f0011 1€►1.000=09-000 WIN
r -rRUCU011T,1 M1:rLrtliv C0CTS
$422.710
®
JAN 2 0.2004 Ar YETW T S IDWE 11'0W
MUMAN M
CITY OF LA 411INTA
FINAYC,E DEPT.
RECEIPT
D� E
BY�
DATE FINALED
INSPECTOR41-
_
RP
7
r`i
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
Steel
POOLS - SPAS
-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Equipment Location
Underground Electric
,3 -
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
3. _
Waste lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
_
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sevr Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
-
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: