0310-321 (BLDG) LICENSED CONTRACTOR DECLARATION �A PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
� DATE �- VALUATION LOT TRACT
W Professionals Code,and my License is in full force-and-effect: ? {�
Cn License# Lic.Class. Exp.Date% �.1
JOB SITE APN
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813480 �3StC r' �/' 2/Zt ADDRESS S�3-g(J7'C«J'.T. .A �+ 78x-U9tAl�}a�!
0 Z rl- 1 at/ � 3S/, Ignature of Contracto. ,.�'� OWNER CONTRACTOR DESIGNER INEER
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C:) OWNER-BUILDER:DECLAR TION PTJ''F1��,AA2=,PAR7M D�AVISRMM
W LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's 177100 SW UPPER D001M M- RY 1£s9 wxONY ROAD,PI'.E" 105
~ U) License Law for the following reason: POWMA'1$D OR 97 21241 EMM.41TAB CA 9202A
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
b60)Q�3�d�2350
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Cf) C)de). exempt under Section B&P.C.for this reason SALES Z PWLE.R.PER MLfP 001427 TPA.CT r� 30 6 EXPI F2 MARCH,
N 30.2004 Date Signature of Owner -
ON
Q WORKER'S COMPENSATION DECLARATION
C:) z I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' VALUATION 51000,00 "
X W L compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
07 Q C) ( ) I have and will maintain workers'compensation insurance,as required by
O L) Q Section 3700 of the Labor Code, for the performance of the work for which this
Cc LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Zl3RIC,14.AMErtI+~AN Policy No. 'C2r3889�'La3 �T�COST 17 'G id t1E`.7ICJJ1�' :x,000 3
Co
0 Pk'�1bDT FRE SUMMARY
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(This section need not be completed if the permit valuation is for$100.00 or less). TFIMP CONSTRUCTION TRAILED 101.000423pdM $200.00
( ) I certify that in the performagce^of the work for which this permit is issued,
I shall not employ any person in any manne..so as to b.ecgme.subject to the
Workers' compensation laof California'and agree�tb-!t O
ws houltl become
subject to the workers'compensation provisio s o S�pop 3700 of the Labor
Code,I shall forthwith comply wittY�t provlsr hP' j
Dater Applica it
GQ� Warning: Failure to secure tNorkers'�Compensation coverage is unlawful and D
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 9
of the Labor Code,interest and attorney's fees. NOV O 4 2003
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 CITY OF LA QUINTA r:
application. ti. FINANCE DEBT. X14
1. Each person upon whose behalf this application is made&each person at SUB-TOT AT,CO1 917RUC"TTON MD PLAN C�:IE;X $200,00
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 TIF-US PRE-PAM FFC.3 110'00
& 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 TWAL PLCMAf)K10MS DUE POW S2Qp.�
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-arid st to thai the above information is I III II VIII III III I I�I 30
• correct. I agree to comply with all'City, and State laws relating to the building IE
construction, and hereby authorize rep�esentati,es o this City to enter upon
the above-mentioned property for�inspection •urp,s S.
I� D iECE1PT DATE / BY`J �� TE FT.LED IN CTOR
Signature (Owner/Agent) / -'- ✓'i'" � - Date�I 1
./ [.�
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 Wail Firewall
Exterior Lath
Drywall-int.Lath
Final
Final POOLS -SPAS
BLOCKWALL APPROVAL§ Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.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 OX 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 VoRage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)