0309-102 (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.
Sas . C13 HlC 10' 112E.
r
Date y� 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.
Ptr I have and will maintain workers' compensation insurance, as required by
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 STA`T'E C"Ck11+11'C'?fi�&il. - Policy No, t}96=4366d'-�fl03
(This section need not be completed if the permit valuation is for $100.00,or less).
O 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.
Date: � I
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, ih
addition to the cost of compensation; damages as provided for in Section 370.6
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. y
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/Ag ent)""'+:G Date
DING PERMIT ' PERMIT#
DATE VALUATION ' LOT 03M-102 TRACT
JOB SITE
ADDRESS 4914544VM COWYWSTYe?DQ4?
APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
Zv mm pr,,wLOr 1,6cwT . CAL702UTde%.,P U- &SPAS (TOip, mm coi
'O BOX 1716-A 86-100M7'(E 54
4.A Q1. WfA OA, ' 92253 COA,-_Hw.k OA 92236
Q60)398.9222' MLO O(s4555
USE OF PERMIT
FOOL AN•. IDR SPA .
PODUSPA, BOO(ANS] t21-534995):. Ai A:R'M ;Ai.iJ'8R3 3HALL I32 . .
IN PLACi? AT PRE•PI A;ITER INSPECTION.. EQTJ1Ph4ENg° ENCLOSURE NOT
INCLUDED
POOL AN1WORSPA P9,0ttQ.Dl1 W "
'ESDUATM) {7,0&" Ciy cn..ffEid�a'.T7f.,.'r191j
1.9100D.00 ;
.R.i"'...d.iA1A`.S is 1�161N++y �l.'d19•,7..� Y. .. .. - `..
.
PLAN CHECK FEE... : '. .' .101-0.00-439-.318 $123M.
.
CON91'RUe:.'!'ION F17, 101-000-41 S:-000 $648.04 '
MECHANICALFEE ,-,POOL 101 u000 -x['21.000 , 04.00 .
6ELEC" t'RICAL F ER.— l<'OOL.... ).01-000 420-000
Pl,Utt4umGftr -= !'om 100 r00Qf419.-0W. ': o' i,46t►
L?3G`T ON AMD PL" s:"Ti1?? X
..$422.70
L r 3 PRE -PAID +
$0.00
0T.ALYERWfYEF8 U',ENOW
1,5
SEP ,2003
CIT` OF UA OUINTA
FINANCE OEPT.
RECEIPTDATE
'
BY
DATE IN AL
INSPECTO
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
I DATE
I 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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel _C7L
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover c3
Equipment Location
Underground Electric
Underground Plbg. Test '
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
aste Lines
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation 5.
Gas Piping
Gas Test
Appliances
44
Final
COMMENTS:
-
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)