9801-060 (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.
74.31.1$
Z
/Date �%�ti%< 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:
( ) l; ,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() 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.
TOO
(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 gree that.ifrrlrshould become
subject to the workers' compensation provisionlof Sectione3%0 of the Labor
Code, I shall forthwith comply with those provisions.
Date:' Applicant 'tt: r,Y t .
ming: Failure to secure Workers' coverage s 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 Ouinta, 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, nd State lawos relating to the, building
construction,. and _hereby authorize representatives f this -City to enter upon
thea ove mentioned property for i sp ction pu%iposers.
f r' . i f,.� t Date
Ignature (Owner/Agent)
PERMIT PERMIT# CONTROL#
.BUILDING
DATE VALUATION LOT 9801!..060 ,TRACT
1/ 9/98 $29.800.00 71 rTY
JOB SITE
APN
5
ADDRESS .. 50-375WSTA MONTANA
OWNER
CONTRACTOR/DESIGNER/ENGINEER
DEWS F ROBER:TS
DESERT DESIGN C0NS['RUC, r..K_)N
M375 V1S rA:.N1d T.;°ju':ANA
82388 0L A.N'DER..AVE
INDIO }o>; CA •92201
IN.DIO CA 92201
.(760)347,5979 CBL,# 4998
USE OF PERMIT
POOL.; Pel Bi: 'iO(A.,F 4' NVI FFNC ENO,
"�!i(O�'•�J
�,(FUI/,/ ''.moi f�(,�/l�'!'✓ t
POOL ANWOR SPA, 25,("100 LS
4 FT. WA i. 300_fj0.Lr
r
' 1:53`DP1�A'1:11? C:`'t7ii'l' U't� Ci,71�iS"t'Ittt7C'2''fO1V '"°"
... 23,81#it.iNf
PERMIT FEE 9UMM RY om
I.—
KJW CIiECK :F :EE 101-000-439-31£8 $.1f34,93
C�JNS'CkUCT'I.(9NE�F 141-000-4:IS-tJt)0 54.50
.
Nb~CHANXAL 'FEE" -A :POOL. 10:1-000-f1 1-(100 $24.00
ELC,CfR[CAL IFFFS --'POOL- it)1-000-4?p-000 $45.00
�
PI..t.7MB(NO17FE P00T, 141-ID(1011.9-00{) S27.00'
SUB-TIYIAL CONSTRUCTION AND PLAN CHEWt.
$565.4
LESS PRI�'-:1��11.D f 913
`.i $0.00,
a TOTAL P'ERNIff FEES '[AVE NOW
$665:43
RECEIPT
DATE
BYJ
DATE FINALED
INSPECTOR
1110 _�
INSPECTION RECORD
0-1
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 Wail 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 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
Final
COMMENTS:
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.1.
Smoke Detectors
Temp. Use of Power
Final''
Utility Notice (Perm)
'dry VQ•way work for Dr Dennie Rot) e•r�.u,'a'S�fr�S
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et
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ILA 'QVINTA7 BUxT•L)z.tJ(l'R °UFPARTNtNT
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the La QuirlVa Polo
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4exa.m
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for peke', pooh � ,r
1
;. 't7pcepsed tenni p covj.,t fe ;
' ttcix h!landscaping' arid.
'dry VQ•way work for Dr Dennie Rot) e•r�.u,'a'S�fr�S
`l4cit�t�t,k Lot- 5 TR J'ol104 lA�e, tbp ��rl'ders��a�ed &pp,'aiovq
et
i Shii 1 y p, McGiriiay �.
itis �} �3 . �' � �':;#R ♦ :�. .� - .f'' • �r +y ; . 3'• t ,; y1 J
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It is the - responsibility.,of the' General Contractor- or the. OWner/Bu.ilderto monito-r'the sub' contractors 'that
are on this.list. 1. ar I e t . he same persons, performing the work: Any ch . an - ge . s' t o this. list,must be approved the_,,,.
City of - La Quints Depirtrhent of building. & Safety , prior to work. being
eing performed by. a changed' sub-
contractor. -
h .anged'Sub-
contractor.- Failure to..comply will result in a.stoppage of wo.rkand/6r','ih6.','vb'ida-ncd of building permit..
* , - q
CITY.."OF LAQUIINTA;
SUB -LIST
`CONTRACTOR,,ADDRESS
OWNER
7_�
�7_
osADDRES S
:3 75-- A/_ -yd- -
This form stiall be g)ost'ed
on the lob with the Building In
pectio`h'6�1'6'tiailll times
. , - U r,
in a nsg)ic 6u lace.
It is the - responsibility.,of the' General Contractor- or the. OWner/Bu.ilderto monito-r'the sub' contractors 'that
are on this.list. 1. ar I e t . he same persons, performing the work: Any ch . an - ge . s' t o this. list,must be approved the_,,,.
City of - La Quints Depirtrhent of building. & Safety , prior to work. being
eing performed by. a changed' sub-
contractor. -
h .anged'Sub-
contractor.- Failure to..comply will result in a.stoppage of wo.rkand/6r','ih6.','vb'ida-ncd of building permit..
* , - q
GRQDEi
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