0208-172 (DEMO)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
451,0301
.Date �' Signature of Contractor�A�'�r''`
i OWNER -BUILDER DECLARATION
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).
()" 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &,,Professionals
Code). . t / 1
() I am.exempt under Section , B&P.C. for this reason
Date ? ill' /o '� Signature of Owner . /.�` ✓x ..M
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
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 )is'�41Pi Policy No.
(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 a Labor
Code, I stiall%rthwith comply with those provisio6ns.
Date: f.r'` ';� /. Applicant r ..� �'. �" �. - -.. _ "�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fine's -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 if
work is not commenced within 180 days from date of issuance of such
permit, or cessation oPWork 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. r
Signature (Owner/Agent) Date
' BUILDING PERMIT PERMIT#
DATE VALUATION_' ayr LOT TRACT
JOB SITE
ADDRESS i,'J� IS��Ed?I EV%�xoF�IT;
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CIV R`CLrX'ONeL D-TuMar
'All DURREErLN91RUCTIOU
1siAA
._?SrMMAMqRaTEZ
tOd-0Pd
(760)77-1-4368 CRIA, 146.03
-
USE OF PERMIT
601.x.1+. 6 0ARDEd VVAL11.0 GITY STANDARD
'Esin"Mr) C011911 OF C-0 XMIturcnon
010D
ft"MMIOM SUMMARY
DEMOGI',MCIN &?"T 101,,000-423-0%.) $43.00
4tWWf t0'i't L CON'S'TRUCTION AND PLAN G"1TR5
= LESS' 1:xM^PAMIMS
$010
�L PIMMY11 FEES DUE now
51451W
MIS 1 � 7002
car OF LAQUIRTA
F"CEOEwr.
RECEIPT
DATE
BY
D INA D
INSPEC
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
BLOCKWALL APPROVALS
POOLS - SPAS
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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Comas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
-.- ..............
.......................................................................................................................................................
FROM EMERY LAND CLEARING RECYLING FAX NO. : 7603915839 Aug. 08 2002 08:46AM P1
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
HOMCAMN OF oeMoLffM OR ASBESTOS RNOVAL
218M F- Cqft oft Dbmofd ON, CA 917W4182 M 39 2000
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PRO= W= STAAr
CLASSO
AlONFMANOWTODE FRiAmE CLASS I
COMPONBrTS
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AWWOFEAWTVPEOF ACOUSTIGGEMG UNCLEM 89HATION Fmppoxm L7 STUMO
pagan=
13RYVBU RASTO OTHER
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KANE
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Witrwo 10V
ADDRM
crry STATE Ap C" STATE MP
Asbe*swnepare mmkwp"Dwdihmand RmvaWn
ENVIRONMENTAL
KLEAN. UP,
CERTIFICATE OF COMPLETION
THIS IS TO CERTIFY THAT AN ASBESTOS ABATEMENT
PROJECT HAS BEEN COMPLETED IN ACCORDANCE WITH
SCAQMD RULE 1403, STATE, & FEDERAL REGULATIONS AT:
COACWUNffY RECREAITON BXT"ING
77-865 Avenida Montezuma
Ln Quaita, CA 92253
JOB #
EKU-202-0109
Removal and disposal of friable acoustic ceiling spray, located throughout interior of
building (approx. 2000 sq/ft), removal of non -friable asbestos floor tile/associated
mastic (apprbx. 180 sq/ft, brown, S/W room & N/W garage), tan exterior stucco
(approx. 1500 sq/ft, exterior of building), and roof mastic penetrations, per survey
report provided by Scott Morrison & Associates,
Dated June 26, 2002
DATE
August 10, 2002
JOB NAME
Coachella Valley Recreation District
Al DurTent Construction Management
WITNESSED Y
Beverley. Gann
P.O. Box 285 Mira Loma Ca. 91752
Phone.(909) 685-5314
Fax (909) 681-5559
ZO 39Vd n713 6995-T89-606 00:81 Z00Z/ZT/80
I
CITY OF LA QUINTA SIJB-CONTRACTOJR LIST
JOB ADDRESS -7 7 -C<%S 1U6. 1ANTea MA PERMIT NUMBER OaOO—! 7a_ OWNER &I,/• 4� �Q��?- p �.o��BUILDER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are auth work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested hPrt
lnw m�mt hp mm�iptoarl by nnnlirrnnt 1'rlr, 01-11 * --
Trade / Classification
- Contractor
-
State Contractor. s License
uPP..v—i— v„ , naa w "WL ail 0%,%,VJJl4U1G IGJI,JVI IDC.
.
Workers Com ensation Insurance , ; .:.
Cit Business License
Company Name
Classification
(e.g. A, B, C-81
License Number
(xxxxxx)
E
Exp}' Date
(xx/ix/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
4602 0,LA4A1,t-
007183
8:31-02
E uA)
7 -
FRA MING
FRAMING (C-5) r.
I
STRUCT.• STEEL (C-51)
l
MASONRY (C-29)
?
PLUMBING (C-36)
LATH, PLASTER (C=35)
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10)'
ROOFING (C-39) : .:
SHEET METAL (C-43).
FLOORING (C-15).:>.
I
GLAZING (C-17):'...+.-.
INSULATION (C -2j >
I
SEWAGE DISP. (C-42) ..
PAINTING (C-33).
i
CERAMIC TILE (C-54)
{
CABINETS (C-6)
i
FENCING (C-1.3)
f
LANDSCAPING (C-27)+-.:.'.;
i
POOL (C-53)
J I