0210-045 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisionsof
Fes— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
0 M License # Lic. Class Exp. Date
� L.� 1556128 CS3,T CI 117` 8 /01
_E
.� Z r— ,.-Date ;"��} ��•"' Signature of Contractor
O0. r,-
r— o _ OWNER -BUILDER DECLARATION y
W W.I hereby affirm under penalty of perjury that I am exempt from.the Contractor's
~ a''*'- 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).
( ) I am exempt under Section B&P.C. for this reason
LO
N 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. 8t ! tY3� 1�F{S�I;I,t ', Policy No. t f61iI34•fi?b�41
(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 Sectio 3700 of the Labor
Code, I shall forthwith comply withtiose prove ions.
Date: -/YO
'dti : Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
BUILDING RERMIT PERMIT"
DATE VALUATION LOT Oda EJb :g TRACT `IK
.F .. 1.01 r � 7, Lt0.63t1¢
JOB SITEAPN
ADDRESS 7$ ;/ dig 4MfiX aDIA
OWNER CONTRACTOR / DESIGNER / EN (NEER
TO T_3.ITy"JM.i.E'tiKL-01*)%4F1q 1C C,t'TAT'ORNIA Poms a spm (MP mmCo.
110 33t'X 1716 _ _ 86.100 .f3�.''.iM..EA4 _.
11 �. CA 92233 CaC)MI—IR3:.IA CA 92236
P/Got.)398.9222 WIN 00355
USE OF PERMIT e
.pom.AxwoYt Falb. z
IMPORTANT Application is -hereby made to the Director of Building and Safety,
for a permit subject to the conditions and restrictions set forth on; is
application.
1. Each person upon whose behalf this application is made & each personat -
whose request and for whose benefit work is performed under or pursuant;to a
any permit issued as a result of this applicaton agrees to, & shall, indemnify '1•
& hold harmless the City of La Quinta, its officers, agents and employee's. 3-
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 foinspection purpo
Signature (Owner/Agent)' �'� �'jl3' tJDatef t.
s. .
Pf)DUSPA,, rs1.4PUAM_ IERS SHALL BP IN PLAt:E,d1 E M&PL.ASTUR,
i'kiOL C! IM r,�OUIP14IR4d'I" il'NClAMURE NOT .l}aCUIDED
V 4LU.d TICITT
11,500.00 ).,S
MAN QIFJECX FIVE 5122.1"
COA STRUC`PI FEE 101-000-418-000 slao t1()
W -C:' i-0dit`.ei' L PER .- POOL. 101-0004-21-000 $24,00
1V1LSC:'ITRIC,Fl.t. Mit POOL .101-000,420-000
P.taZ1R9MO PUT POOL 103 X000,419.000 MUD
8uk_T01A.L C:°C�23I iY�ttJC' d'1t 1 t�i�fiJ '1, F ("T.C"
tax
[r%3- u T(Y- E, P'IT 77110KKI S _DUH PIM
OCT 082002,
CITY OF LA QUINTA
nmANCEDEPT
DATEBY DAT F ALED
i 17ITM<M
$407:8:5
$0.00
$40 lhIS
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
POOLS
- SPAS
BLOCKWALL APPROVALS
steel
1p '_ems
Set Backs
Electric Bond
40
Footings
Main Drain
/7 rfZ JPW
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
Encapsulations �J
Gas Piping
Gas Test
Appliances
Final,
COMMENTS:
x
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)