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` t * LICENSED CONTRACTOR DECLARATION
7, 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
�i3��JR14 b B M- C A. V30/04
Signature of Contractor /r `�-
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
I:
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.
. ( )`'+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 jssu�d. My workers' compensation insurance carrier &; policy no. are:
Carrier a�'Batl$rirhdiJ Policy No. .SJI�:Y-tl7.
(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,
•,--1•shal1 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° hall forthwith comply with ase pr6visio6s.
-Dat `^ r, - C.0 Ann icant
Warning: Failure to secure Worke s' 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, Inde
& hold harmless the City of La Quinta, its officers, agents and emplo-, ye1?;.
2. Any permit issued as a result of this application becomes null and low'f-
work is. not commenced within 180 days from date of issuance of�lcc
permit, or cessation of work for 180 days will subject permit to cancello
I certify that I have read this application and state that the above informa on i
correct. I agree to comply with all City, and State laws relating to the b Idin
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prope y fo inspection purposes.
�l f�
,,,-Signature (Owner/Agent) Dates
BUILDING PERMIT PERMIT#
DATE/� '! VALUATION �oS.pf�f• LOT S TRACTJOB SITE
,.
ADDRESS $&,2 -00 V&6;V4P J .00 APN
OWNER CONTRACTOR/DESIGNER/EN (NEER y
' it V'r�g�� i 3�'y1 F ,�yf 1 �.gy �t
Far liy�w�i���;y��'d�`y�d�i"3���"gI's,, vJ:t/�i�c� , �
1425:11L. 11JM 1..A7�.r iJl6 MIM, 142.5 E. tJS. IVE/1�'A_�AI .�. ¢6RIYe:• � y
vvrrr..�?*m.' a•is as .� rr.� sa p . s e 1e
k'Xav1"wv.L�. AZ 45035 � PIRIOas�v'a�r .dpi.. 8s.: toad
('6,02ps•J�-1656 CDU 4990 t
J
USE OF PERMIT
POOLAIM/OR SPA `
rr4rr� rrnn r.: x.�:i it ddme � nn+an ae ., n_w r�ax.a •. � h.wam-n rt. r..:.� na x .r ;..,x �.
P W Z Pk.10 TO PFLIP LAS ` Z.11 18PeCT1014,.... .r.. w .
P4CIOLAlqWaR SPA 15.00 .00 LS .
E 4."DAATXD C;09;>w OF COPS U?C'11014
i's�.'2�'iC 1.1 BEV. &'ori
P LI&N CHECK TIRI 101>000.439.318 $305.30
{:ONS't'RUCTIO';.•Q ME 01-00"18-000 00
MEC'HtoNICA7.. FEf:: ,.. POOL 101-000-421.000 312,14.Ui3
=XT c` ICAL .FES - POOL 101-000-424-000 T45.110
P1a11MDT► 10 .FEE -- J'4.7OL i 01.000.419.000 $27.00
a
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TOTAL. I'F-RMIT JMEN I1•i11.t:NOW .
0 6 2004
v
-;� MOO
TTY Oe i A QUINTA
FINA%CE DEPT. ✓✓✓
RECEIPT Y DATEe/ ,rr�'BY ` C DATE FINALED INSPECT
n
.<Er
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
steelt-
POOLS - SPAS
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
-,?N
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
Final
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:
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o N
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TW
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TF
WALLS!(TYp
42.49 TW
72.84'
35.15 TF
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PATIO
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6 FG
'pl,50-210 VIA SIMPATICO
VIA SIMPATICO,'
.w ® �ft
F _
603
; 38.1
PAD • — 38.1 � �
ASS 38.SO '
r
0 PAD = 38.1
,i
y 37:2 ' t N _ b! 6¢? T��' • FF — 39.60
i y F�-HP, PAD = 39.1;
a FF
PAD = 39.1
FF f
39.60
t:..: �: • GF = 39.10
N ;�„ �� p PAD' ° ,
r<� ?K cti ..r. •- .0; rr' �, 6.00' - N e'
37.7•
—
1:� 50;x• s A WINSP ON FEE
elOsS� 616 ,jF i ss� ods ILL BE CH ED FTHE
PLAN15+0
AN ARE NO �N
( T % Hwl ---}--
ION
s NO E KCEPT d
• SIMPATICO f . �' ' ; ;< 35.97) '
A, s ,`�� TC FLA .QUINTA
C
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rr OFA 93 1 �/� ;.
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RUCTION
36.64 F
,i ; .� �� ,:_ ,.; ,• ,� DATE
mid :., : j .i°':� r I �, ,)•3�8' •. ,, � • ,