0108-116 (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
=` Date 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). .
( ) 1, 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 have and will maintain workers' compensation insurance, as required by
S 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.
ACCEPT MCE IkiDO
:(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 provisions of Section -.3700 of the Labor
Cole, I shall forthwith comply with those, provlsionss
tEate: Applicant—
Warning:
pplicant 1 l
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
any permit Issued as a result of this applicator 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 cess'atlon 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 authorize representatives of this City to enter upon
the.above-mentioned property for inspection purposes.
Si nature 'Owner/Anent' f ' Date '
9
BUILDING PERMIT PERMIT#
DATE VALUATION i LOT . �J'� QZ�^ �'tii TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
BUB -PILE SIMMS
555 555'PPIMIX.�MACH
71 SC:+1 ice+ GO�:GONIO
L& Qui1�' A CA 92233
�';.ANCx.;Ii.:� M'.�i1 GE Cin 92270
Ci61)341-23; 6 -SUf '�S486
USE OF PERMIT
11001.6 �l�. R n�jA
PO�.oUS'f'A, J9.L�.Rit�dtVUR.I.)M'`I ST-i.FiiLLB fN .PLACE.i 'f PR&Pit/tSTFR '
1)�iDPWTION. POOL i1QUIP.;�si NT ENCLOSURE, NOT IN!f;,LUD91.
POOI. �? IMOR SPA 54881.00 LS
X WA.Ed' D 6.rafg O �1{.�'dgS.Li i�4..J..i0
wi yl7Ga�+67i!
�+q )1ya,�v �l �'y j�• p' j yy� /� %
�t��, Q •Ti1�V f'Jr7L..(y�.f0.3/AbY�..Y
1` I`I -041 CUCK f�'!� E? 301-000-439-318
«:'il'�Yf�'3`Y��1GT1ON FtK'E• 101 -000.418 -CCI Ka. 00
hal CURANIC,S�L Z •- POOL,.. 191-000-4•21.•00£3 %24.00
6;'�M�I� ". P015L : 10- -0 30420€ (9) 145.00
PS,1.12M«A11�;�91��14. _� POOL 30n09PT. $27.0 0
AUG
CITY
F N
1 -'i °�'. iL Csomff^ek1.1'ffl fou Y,I1,C17�3;AN CII -M
132.241
$ 0.00
RECEIPT
DATE
BY
D E INAL
INSPECTOR
INSPECTION RECORD
OPERATION
- .DATE
I 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
Steel
Set Backs
Electric Bond
g/a� er— �-
-�
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
5
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
Sewer Connection
Pool Cover
Encapsulation
a/M!/P
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
AUG. 3.2b1a1 9:55AM CDS 110.1El P. 1:1
FROM LeSL Concapts FAX NO, 7503421675 Rug. 03 2M1 10:49AM P2
SfNT 8Y:' FGA WCOT RES!"dBTTAL ASSOC, r; 760 771 51,25; l+uG : Ci t:y:G7AIj; FACE ;!s
A-Y'
r _
1A INERT
(IlDeRTIAL AMMATION, INC.
My 180 2001
ley and SUSM Menneksm
5 5-5.53 Pebbie8each
La Qtdtat%; CA 92253
DOM No. read Mrs. Menrickscn:
Mr, Don Adalph, ArcJLitectural Cgmmittee Ch31tt Ut6 bw approved your request to act a offLa
ad(&ion, a ww pool d6CL and t*.ar landscaping at your SS -SSS Nibble Beach mide=- Upon
conmp1060A p19M subunit tho enelosed Notice of Cmplemon fovea to this office.
Prior to comtu,et,t ==1 of work, in,cltAng demolition, -the following mm bt provided:
L 3:5.00 Applicadon Fee
2.115.00 Riverside Couaty Rcrorder Fee,
3. Cottttector's Proof of instusace
4. Conor itis Lkame Number
we reserve tbo right to melee a f n4l iaspeotian of this change to make s= that it maa= the
be
tmpesL A approval is based of y on the aesthesics of your proposed plan aW should not
Y wrtficMcn sato the cmtrucdon wod%Wess or sQttotluw inteerlty of the prop
cblt�e.
WC IPPM OM Your coopecati n itt Submining this mquest for approval. 'If I may be of fwther
asointaat e, Please contact me pt tlg ROA office, (760) 771.1234, 5x jvion 1 S.
Sinsarely, _ .
y
op mlions Mama .
Msao
. ae: Aacltltecttie�i Corttmittee
PD. Box T060, La Ouinta, 0a)6*11li8 92253, Telephons 7d0w7 ?1.1254 FAX 70471.51Z