0210-074 (RPL)LICENSED CONTRACT& 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
ProfesFjonals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that [am exempt from the Contractor's
License Law for the following reason:
XI, 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&PC-•for this reason J
Date �✓e'3 f� i''1 r) Signature of Owner
WORKER'S COMPENSATIONp ECLAR' TION
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:
Cartier Policy No.
(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,
Vshall 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 Sectiopy3700 of'the Labor
Code, I shall forthwith comply with those provisionsri �/�
,.Date: e/1,_A'� "./' Applicant -t' ir'l Jf,d �."
Warning: Failure to secure Worke s' Compens tion 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:'bf 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/Agent). '0 /r ;'XV/ Date b, r
BUILDTIVG PERMIT PERMIT#02-10-074
DATE .l. ; /f / •� VALUATION LIT TRACT
5,0 .34 971-1
JOB SITE
ADDRESS WAI e;S�.WWA
APN
6504'•211-W..2
k�
OWNER i
CONTRACTOR/DESIGNER/EN (NEER
17��Cj.`1iy3,r}�n. 'q}'• fr J��td'.tt�7:yk�PIR �.uILE�'
t,"D�1+�i:Ai�:�'� P•[3'1, -Dm
18-520 VIA A j w .t � ilA, .
LA Ci•(%1.'?� A CA 922S3
;1 (MIX
USE OF PERMIT
POOL AMMOR WA
P001.PIWl4.. ALAR.BA.A.f1K.pt11?3:;1.;H31A, 3Z 114'P1.nliC,E.Pi`P'PV%.UMFX"i eR
l�l•bPhE`3'it1�, �r��1�����' l�'I`1CI.:�i�Lll�.�'���' t�iC��.t�T�.l��r.
F'C+O.i,AND1012 3PA 1313 .i+p 1,S . .
1"IME A3`. 7) C01,71' (W (; O.K&INUMON
PERIAGTFER
L'P.tJiA.f7' T'.SZirl.i"rT?. SrSr 1. AJd ��I'V'V'�'Y a�//'1['✓ 847' +Bd4i'10/U'
.
COAIS4a1€UCTION IFEE 101 (3(3p -d 1• d-€?Cft'1 '$16L.ftu
MitiCt,..A 41CAI,, ME -- POM 101.000-41,1-000 $24.00
KLE-CT 1CA L FE19 — POOL 101-.00f1-1.20-000 W.OV
T'1�iJ ,1F1i A1q i` ':-• P�E.� 101.00 -41 9-000 V7.IiO
A
0CT 0 7 2002
rF
CITY OF LA:QUINTA
FINANCE DEPT.
ST P-_1 T:XLCaRar4 la-T,X
63.30
MG�1
ft10.9 iR1>°'P9si'TIM
,+'•
�i'iV•��7
;..i
V
RECEIPT
DATE ��
'B- ,�
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
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
t PLUMBING APPROVALS
Test
Electric Final
Waste Lines
Heater Final
Waterd'iping
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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 '
Date 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.
( ) 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 Policy No.
(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 Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 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.
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
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT# r
a
DATE VALUATION LOT TRACT
:��lCDr�CdC `�'��,4�,1�'3r(ki) 34 ;''+71-7.
JOB SITE
ADDRESS u SS 78- 0 VLA VE -L
APN Chi- 1032
OWNER
CONTRACTOR / DESIGNER / EN INEER
'RoB,.In r & )r.I1 i CT.l:LLUX
OW -141A. BLy�. DUI,
LA QUNTA CA 92253,
USE OF PERMIT
POOL lANDIOR ISPA..
PCCL ISPA, AL RNIS31iARRIER.a SI -L BL? 11-I P.' VCP A1' ;PMPI.ASTZl:
MPE':T.MIK. I?(?C.fIPMCI H INC U URK NOT TN.C;fX1XR,,D.
XX)1,.AW9)/0R SPA 1A000.00 LS
Eb-M. .14 c.og m v communion
PLAN CHECK OEM
C OVISTRUCr' ION PKK 101-000-418-000 WIWI
MECHANICAL M _.. ;u001, 101-000=421-000 $24.00
JvLEM'XIC1 L FEZ— POOL 101-000-420-000 igJa.OU
PiXiai,ki➢4SntFRE Pool, 101-1300.419.001 $27,00
SM -TMAL CON MR AND P -LAN C;`�}.T�CK
$363.30
LESS '}'12EvPAM TIME a
$0.00
10T&L PTT 1':1' FLIMS DUE 3Vi'}W
AZ
RECEIPT
DATE
BY
DA E FINA D
NSPECTOR
It - cr 3
.
t
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
.ems'
Footings
Main Drain
Bond Beam
Approval to Cover
=
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
Finals
0 3
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)
COMMENTS:
}1 �
/D -�' ���z -�
CITY OF LA QUINTA SUB -CONTRACTOR LIST �
JOB ADDRESS 7�-.5�?D �li1� 5��/IC.Lf? PERMIT NUMBEJR 102.11D Oli NERk(.)6 (Ek/y,/F f2 (-L61,)BUILDER
This form shall be ostedon the 'ob with the Building Inspection Card at all times 'in a conspicuous place.: Only persons appearing on this list or their employees are authorized to work
on this job. Any. changes to this list must be approved by the Building Division prior to commencement of work. Failureto comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. On File��is not an acceptable response.
Trade / Classification Contractor State Contractor's ,License
Workers Com ensation Insurance City Business License
Company Name Classification License Number Exp. Date Carrier Name Policy Number Exp. Date License Number Exp. Date
(e.g. A, B, C-8) (xxxxxx) (xx/xx/xx) (e.g. State Fund, CalComp) (Format Varies) (xx/xx/xx)
pD Ixxxx) (xx/xx/xx)
EARTHWORK (C-12) /,,�,.,_ f i'/ %�� 5T 7 ?% E7 pTJI�.��
CONCRETE (C-8)C'/U/1/fe��e�1-2T _
FRAMING (C-5) Q Qf
991A*1-7-k C36/
s
Sim/GS
STRUCT. STEEL (C-51)
MASONRY (C-29)
PLUMBING (C-36)
LATH, PLASTER (C-35)
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10) G
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING (C-17)
INSULATION (C-2) :
SEWAGE DISP. (C-42)
PAINTING (C-33)
CERAMIC TILE (C-54) 0
CABINETS (C-6)
FENCING (C-13)
LANDSCAPING (C-27)
POOL (C-53)
991A*1-7-k C36/
s
Sim/GS