0104-295 (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
tai+ 1 ,R CS3111V" �'10,31/W
°
Ij e ° 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).
() 1• am exempt under Section , B&RC. for this reason
Date Signature of Owner
WORKER'S COMDENSATION 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
`y(u.
Sdetion'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.
STATE COMPh"HUMT1
(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
subj cit to the workers' compensation Fovisions of Section 3700 of the Labor
C e, I shall forthwith comply with tho e provis'ons.
Wate: x f 14 ' Applicant
Warning: Failure. to secure Workers' Compensation verage 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 ifj
work isnot commenced within 180 days from date of issuance of such i i
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
construytion, and hereby authorize representatives of this City to enter upon
thea Eve -mentioned property for inspection purposes.
S' nature (Owner/Agent) - d Date k
BUILDING PERMIT PERMIT#
DATE VALUATION LOT77 ±. 104 - 5 TRACT
' i d.57yL''J'QPJCP4.e 61 '
JOB SITE
APN'
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TD. Dlir'RMT;1 nI T-111LOPWIN
CAU1401MIA POOLI► fir. splis ("t'OP 1:'. m col
R0, BOX 1716
747 25 J0N.1 Y?.Et;1'lYF, UICAM, A
'LA Q1C1N A, CA :O2L'"a3
PfiJI +S IATZI :R.°T CIA 92260
(mopa-9000 MA 3 .
USE OF PERMIT
1?00.1. ANiVOR #VA
k,3SQ eAVISI 1-558-10,95. i.,,AyL�{�MS//rbAlt,�i�.IPRSt ;.'IH,AL..IL EIV. .
r€'''0.2.y�2q3:6/aP/1.n
�eye'� yy
9 �R'A.✓, 4.E�S:f ff PRE-5'.lU"brT t i.'.•�R. )J�•[GiA'EC AkrN, i. 001, E:r� It 85�1Y3S:.N°e
POOLAHWOR SPA 181POD100 LS
R611VATIM COTrOff' CONSURUMION
P.U1 WTVk� SUMMARY
PLAN CHRICK 7M, 101-000-439,318 MID'S
CQ3aSTRtaCTION 14?_F, 1.01-000-418-000 V89-04
XClef::EPUCA.t..,l?k�'av Pool, 103-Ci.W-c$20-0+0.0 $45.00
ITITMAD1NG l" FZ POOL 101.000.419.000 s n 00
MWIDTAL (;C'lMMIM1.'�`dl,C)W AYD 11 AN CHisCK
3407.81
I= PICL-PAID FH=
PENME �.r� ES DIVE, ow
�
$0 00
5407APR
3 0 2001
F
p.0 al; I h QmNTA
R CEIPT FI,�
rR ADEPT B r'
DATE FINALED
INSPECTOR
R ,
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
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
Footings
Main Drain
_
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
Gas Test
-
PLUMBING APPROVALS
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
�e��
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)