9801-127 (RPL)LICENSED CONTRACTOR DECLARATION
Vil%reby affirm under penalty of perjury that.1 am licensed under provisions of
Clirpter 9 (commencing with Section 7000) of Division 3 of the Business and
Pre;essionals Code, and my License is in full force and•effect. t
License # Lic. Class Exp1 Datelj
Z, SiS�� 2� tet✓.-�s3 ..I
Date Signature of Contractor Y 7'
OWNER -BUILDER DECL--ARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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.
Se( )' I have and will maintain workers' compensation insurance, as required by
ction 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.
a fA7'R FUND 1034 03-97
(This section need not be completed ifterpermit Val or}�.fi A1100.00 -or less).
() I certify that in the performance of the work f9 hi h t Is ermit is issued,
I shall not employ any person In any manner sd s.t�be •orfie subject to the
workers' compensation awes of California, and ar`e i th/ i I s ould become
subject to the workers compensatI n,provisi A o ect" 37 0 of the Labor
Code, sha o Itfi oomply with thosedpr Gisij r it
•Date: ��� Applicant , x
Warning: Failure to secure fNorkers�compensation coveragefis�unlawful and
`shall subject an employer to criminal penalties and civil fines 4 to $x100,000, in
,,addition to the cost of compensation, damages as provided forkiZSection 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,day Vwill subject permit to cancellation.
I certify that I have read this,al5plication and stat that the above information is
correct. I agree to comply with all City, and State lif aws relating to the building
construction, and hereby authorize representative/s of this City to enter upon
the above-mentioned ro ertfor ins eedsttio%n"ur lose
4Signature (Owner/A ent)" `^--v� �' ✓t ! yF Date
BUILDINGPERMIT PERMIT# •CONTROL# =,
'9801^127 �
6544
DATE VALUATION , LOT 'TRACT
JOB SITE
APN
ADDRESS
79-245 VICTORIA
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PASWATER, JOY
ANIERICAl l POOL CC)'NS'IRUC110N
?9-245 VICTORIA
68575 SAN FELIPE RD,
LA QtA1'ITA CA 92253
CATHEDRAL CITY CA 92.234
{760}329-2156 C B.L# 11.04
USE OF PERMIT
POOL & SPA WI'r€i 2,410 5- BLOCK -EQUIP utENT IEtC"L&JRE AND -MILF
5' ROD IRON FENCE
CITY OF LA QUINTA
JAN
2 61998 '
POOL AJ'VD;OR SPA, Is,aaL:.aa I's
FINANCE
DEPT -�
c ci
sj
ENTIMATED COST OF CONS;"Cl2i3L"t'I.ON •
f8,tt�t31.1t3i
PF,RMff FEE SUMMARY
PLAN CFW.CK FEF 1.01.000-439-3.18 �R22.85
CONSTRIiCI ON FEE 101-000-415-000 $Is9.,0o
MECHAINIC:AL, FEE -- POOL 101-000-421-000 $21.00
8 EMUCAL PI E —,POOL 101-000-420-000 $45.00
PI„ UhtBfNG FFE -- POOL 101.-000-419.000 $21.00
I
SC.f13 TOT- :L CON-MU("`]`ION AND PLAN CI EC1,'.,
$407.135
LESS PRE -PAID BEES
$()Bt
TOTAL PERMIT FEES DUE NOW
5407,85
RECEIPT
DATE
BY
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
OX 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
nruviall _ Int I ath
POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond '
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underaround Plbo. Test IIV, I n
PLUMBING APPROVALS Gas Test 5-11/
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 P
Final I & — 5 T6
COMMENTS:
�paL f R/n its �€A /IJ t='f% ftp- 6d qez
Final 8,/V
Utility Notice (Gas) /yto-)Ar6 ; a s eD&-Z�, (W6/ '
ELECTRICAL APPROVALS A 54r0,1eS Ar
Temp. Power Pole oC /5(ocJS� /9ND
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Utility Notice
4L2,
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