0303-083 (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. t
License # Lic. Class Exp. Date
56'12 C53 Fac c' -VA ^ '/0f
f� {
Date p Signature of Contractor
9 ,
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.'
r
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
perf„pmance 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 STATE C c:?MP1?1MM, Policy No. i11fi-tS1�&-aQtO�
(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/provisionsof Section 3700 of the Labor
Code; -,shall f • rthwith comply with those rovisions:
Date: I.�1S 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'r
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 authAe represerpjatives�of this City to enter upon
OF the above-mentioned property for inspection pur • os s.
Signature (Owner/Agent).V �' `' Date—
PERMIT #,.
/ BUILDING. PERMIT CG03_
DATE " y` 91 lf� � VALUATION ' 44 �����y .LOT TRACT
JOB SITE
ADDRESS t0.P1�aa�e \
APN
OWNERCONTRACTOR/DESIGNER/EN
(NEER
`'Cf UL BIVY.r1up"19 INCA
C_' 0dae01041A p00LS A SPAN (TOP MAN CO
73.121 TiRM WARING, #1 00
e6-3 00 AVENUE 54
Peri I)Epl.Ii.,r CA. '92160
COACMI-1;..A CA 9223
(660)39€-922.2 MIX 0035; '
USE OF PERMIT
F• 001,ANDIOR. VA
5'UU..4al,-J , 011V (AL451 zzl 3t I yw—y) S a i=. a' nta J' , sir c+ r.
STANDARD ALAH.1ti1S411f*,.ELP.Ik): z SHALL 6k IN MACE AT`PRE-PLAST.9k.
114SPECTaON.
Ta. WALL &fly
i OOL ANWOR SN.A. 1.45
ES11MM:3: Cosr OF C%N3"11MUC 'ION
10,0W.75
els-'.!g�i';��i+."� fn'�7'?1/.tNlll����k�' • ,� .,�
,
PLAN CHECK TARE 1014-000-43-0-318
i 014STR iCTION FEZ, ;$01'000418-00Q (k'iStFS.00
hIECHANICAU— POOH oY ac 0 a �s is S29.IfQ
EGa3 C '9UCAL C*LA,>, POOL". 20-i00d
P, LUPulWN0'T{ E -> PO 01, . 101..,P00.419-000 $27.09
154"2.10
.. Iraq: mm IL 1+'T�tw '
VX 00
e.n�e �e4, n �a yy 1n. A�
' �. � • ',vaa. S xsmeai7'.7d�:1:: 'Hai
AL
MAR 17 2003
CITY OF �_QiljPdT
ECEIPT` IFINANGI
DATE' li•9 e •
/�/ ' /p,
SPECTOR'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Duds
Forms & Footings
Duds
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
Set Backs
Z fD p
Electric Bond
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
Z 10
Gas Piping ;
Gas Test
Appliances
Final
COMMENTS:
_ .....
Final
UU14 Notice (Gas)
.. ELECTRICAL APPROVALS
Temp. Power'Pole
Underground Conduit
Rough Wiring
Low VoQage.Wiring
Fixtures
Main Service '
Sub Panels '
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)