0311-180 (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
614611 C'53 0105
Date l6 fU 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: Fig
( .) 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 A policy no. are:
Carver `Policy No.
Jk1� WILP iC 7000933600
This section need not be completed if the permit valuation is for $100.00 or less).
( ) .1 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: � � 7 tie r' Applicant r"1'ms"
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 ofc ,mpensation, damages as provided for in Section 3706
of the Labor Code, int
eI
est and attorney's fees.
IMPORTANT App licatn 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 unifier 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 1ssuance 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
�he above-mentioned property for inspection'purposes. �e
Signature (Owner/Agent) � Date A
BUILDING? . ERMIT PERMIT #a3t 1 _ Igo
_
DATE VALUATION LOT L -' TRACT
JOB,SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER?=EN INEER
l 70�t 9 fiv�.�:+ � IStiJ(:°
MCTd:1. M 17001A SP/.X
1 77"564 COUNTRY Cr7 LTAP D: iVE RRITh;107
BOX 1791
.PAUM DIW-RT CA 9 211
LA Qi3UqfA CA 92253
(760)360-3$85 (JL4. 4543
USE OF PERMIT
POOL AK?IOR OIL
POO.Id' .P.A. l!:LARI><3NP3tARRISRS 51•i" LL FJR ).-,N PLACEAT FIhLf'. PLA:R'!'!? R
►f�J�r �?�� i�r�, �:���:),��,��;1�f r<�ac�..ta�l,k�r� r�0�' r��L����;�
Pool, "A:ttUORSPA 15,000,00 LS
r
l
l
Ym TM A rm C,r Yr 0 i C Ono ,mt7C"":Ia0-1,Y
p5,1f D,O€J
1i'lf�r7ib `6.' TTM UUWAWN
PLAN C#1 CT,17K 101-000-439-318 �J09,3A
GO;fdSTRUr.'I',t'OW- L.Y' 101-•000-4-19-000 $36100
KEMIANIC AL VIM -- POOL 101<000.421.000 $24,00
Xf.,LF',".TIUCALF+EE—POOL 101-(Jn()-4'io-OL10 $45.00
FX;t1M0)NO FRE -- POOL 101.000.419-000 $27,00
4
,
sMB-MfAL CONSTRUC iW AN'D 1`!. --NN CEREM
$363.30
Lr A 13 05 PRE -P fsTJJ FEES
($0,00
t&:I: F?ts".R-W 17.74 M VVE NO''W
�
NOV 19 2003
CITY OF LA °QJISj uA
FINANCE DEPT
RECEIPT
DATE I �
/ � i' `)_
BY .= f
L
FIN IN ECTOR
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
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location ✓
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Wasrr Unes
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower -Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover r
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
<4 ELECTRICAL APPROVALS
Temp. Power Pole
Ur`derground 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)